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• • • • • • • Approach to patient Identify skin lesions Skin infections Papulo-squamous/inflammatory rashes Systemic disease Skin tumours Skin failure + ER
• Time course of rash • Distribution of lesions – flexural, extensor, acral, symmetrical, localized, widespread, facial, unilateral, linear, centriceptal, annular and reticulate. • Symptoms – itch/pain • FH (atopy & psoriasis) • PMH • Provocating f(x) – sunlight & diet • Previous skin Tx
• Look and Feel • Concentrate on colour, moisture, temperature, turgor, presence of pathological efflorescence, bleeding manifestations, and oedemas. • Assess – Nails, Hair and Mucosal Surfaces
• 2. 3. 4. 5. 6. 7. 8. 9.
Colour Pale – whole, local Red Blue – central, peri Yellow – jaundice, xantosis Brown – localise, diffuse Grey-brown Albinism Addison’s disease
Moisture 2. Enhanced – Local, Diffuse 3. Reduced
Temperature 2. Increase – reddening, oedema (inflammation) 3. Decrease – pallid, cold skin ( ischaemia, Raynaud’s)
Skin efflorescence Trophic skin changes – vascular & innervation disorders 3. Bedsore(decubitus) 4. Varicose ulcer
• depends on hydration of the skin, the epidermis and its structure. Decreased turgor is common in older age and is caused by decreased elasticity of epidermis. In other cases dehydration caused by fluid loss contributes to decreased turgor (decompensated diabetes mellitus, diabetes insipidus, intensive diuretic therapy) or dehydration can be caused by insufficient intake of fluids (reduced thirst feelings in elderly people). The combinations of both causes are frequent, too.
• Thin hair can be found in both sexes in hypogonadism, hypopituitarism, hypothyroidism, and hepatic cirrhosis and in males treated by oestrogens. Stronger and denser hair (hypertrichosis, hirsutism) is important in women. Cushing's syndrome. More severe forms accompany androgenic tumours of the adrenal cortex and androgen treatment (doping!). Alopecia is diffuse or local loss of hair. It occurs in cytostatic treatment, in abdominal typhus, and thyrotoxicosis. In some men, the diffuse alopecia is a common finding. Local alopecia (alopecia areata) is rather rare to find.
• • • Fragile and fraying nails are most common in thyrotoxicosis and sideropenic anaemia. Spoon-shape bent nails (koilonychia) occur in thyrotoxicosis. Spherical nails accompany congenital heart disorders, chronic pulmonary diseases; less frequently can be found in hepatic cirrhosis as a part of clubbed fingers (the shape of wrist watch glass). "White" (hepatic) nails occur in hepatic cirrhosis (the white part of the nail, so called lunula occupies a significant part of the nail area). Nails deformed with uneven surface, thick, changed in colour (particularly on toes) are affected by mycosis (onychomycosis
• Atrophy – thinning of skin
• Bulla – large fluid-filled blister
• Crusted – Dried serum or exudate on skin
• Ecchymosis – large confluent area of purpura (bruise)
• Erosion – denuded area of skin (partial epidermal loss)
• Excoriation – Scratch mark • *Perleche (lip licking) , neurotic excoriation
• Lichenification – Thickened epidermis with prominent normal skin markings
• Macule – Flat, circumscribed, non-palpable lesion. Generally less than 5cm with different colour from surrounding tissue
• Papule – Small palpable, circumscribed , elevated lesion (< 0.5cm)
• Nodule – large papule (.0.5cm)
• Petechiae – pinpoint-sized macule of blood in the skin
• Plaque – Large, flat-topped, palpable lesion
Purpura – large macule or papule of blood in skin which does not blanch with pressure
• Pustule – Yellowish white pus-filled lesion
• Scaly – Visible flaking and shedding of skin surface
• Telengiectasia – Abnormal visible dilation of blood vessels
Ulcer – deeper denuded area of skin (full epidermal and dermal loss)
• Vesicle – small fluid-filled blister
• Weal – Itchy raised ‘nettle rash’-like swelling due to dermal oedema
• Maculopapular - penicillin
• Urticaria (Hives) • Penicillin, aspirin
• Vasculitis • Gold, hydralazine
• Fixed drug rash – Phenolpthalein in laxatives, tetracyclines, paracetamol • Pigmentation – Minocycline (black), amiodarone (slate grey) • Pustular - carbamazepine
• Lupus erythematosus • Penicillamine, isoniazid
• Photosensitivity • Thiazides, chlopromazine, sulphonamides, amiodarone.
• Erythema nodosum • specific painful red and violet infiltrates located on the shanks (sarcoidosis, idiopathic intestinal inflammations, or the origin may be unclear). • Sulphonamides, oral contraceptive pills
• Erythema multiforme (EM) • acute, self-limiting, inflammatory skin eruption. The rash is made of spots that are red welts, sometimes with purple or blistered areas in the center. It often also affects the mouth, eyes and other moist surfaces. • Barbiturates
• Acneiform • comedones, papulopustules, cysts, or nodules that resemble acne vulgaris • Corticosteroids
• Lichenoid • keratinocyte enlargement associated with Civatte body (colloid body) production • Chloroquine, thiazides, gold
• Toxic epidermal necrolysis • Penicillins, cotrimoxazole, carbamazepine, NSAIDs
• Pemphigus • autoimmune disorder that causes blistering and raw sores on skin and mucous membranes • Penicillamine, ACE inhibitors
• Eryhtroderma • generalized skin disorder characterized by reddening and scaling of 100% of the skin. It is also known as erythrodermatitis, generalized exfoliative dermatitis, and red man syndrome. There may also be normal areas of skin present • Gold, sulphonylureas, allopurinol.
Skin Failure and ER Dermatology
Toxic epidermal necrolysis (TEN)
• detachment of the epidermis from the dermis all over the body. • TEN affects mucous membranes - mouth, eyes, and vagina. • The severe findings of TEN are often preceded by 1 to 2 weeks of fever. These symptoms may mimic those of a common upper respiratory tract infection. • When the rash appears it may be over large and varied parts of the body, and it is usually warm and appears red. In hours, the skin becomes painful and the epidermis can be easily peeled away from the underlying dermis. • The mouth becomes blistered and eroded, making eating difficult and sometimes necessitating feeding through a NG tube or a gastric tube. The eyes are affected, becoming swollen, crusted, and ulcerated.
First Line: early withdrawal of culprit drugs, early referral and management in burn units or ICU, supportive management, nutritional support • Second Line: Intravenous immunoglobulin (IVIG) - Uncontrolled trials showed promising effect of IVIG on treatment of TEN • Third Line: cyclosporin, cyclophosphamide, plasmapheresis, pentoxifylline, N-acetylcysteine, ulinastatin, infliximab, Granulocyte colony-stimulating factors (if TEN associated-leukopenia) • Systemic steroids are unlikely to offer any benefits. Prognosis • The mortality for toxic epidermal necrolysis is 30-40% • Deaths are caused either by infection or by respiratory distress which is either due to pneumonia or to the damage to airway linings.
Stevens Johnson Syndrome
• Milder form of TEN; hypersensitivity complex, rare - 1 case per million people per year. • flu-like prodormal period of fever, sore throat, and headache, which may also be accompanied by photophobia and redness in the eyes, followed by the sudden development of circular mucocutaneous lesions that can cover the majority of the skin. • These lesions begin as macules and can develop into papules, vesicles, blisters, or urticaria. • SJS is usually defined to refer to those cases where less than 10% of body surface is involved
Caused by infections usually following viral infections, allergic reactions to drugs, malignancy or idiopathic factors (up to 50% of the time). SJS has also been consistently reported as an uncommon side effect of herbal supplements containing ginseng. SJS may also be caused by cocaine usage.
Treatment • Discontinue all medications, particularly those known to cause SJS reactions. • Treatment is initially similar to that of patients with thermal burns, and continued care can only be supportive (e.g. IV fluids) and symptomatic (e.g. analgesic mouth rinse for mouth ulcer); there is no specific drug treatment • Treatment with corticosteroids is controversial since it might aggravate the condition or increase risk of secondary infections. Other common supportive measures include the use of topical pain anesthetics and antiseptics, maintaining a warm environment, and intravenous analgesics. • An ophthalmologist should be consulted immediately, as SJS frequently causes the formation of scar tissue inside the eyelids leading to corneal vascularization and impaired vision, as well as a host of other ocular problems. Also, an extensive physical therapy program ensues after the patient is discharged from the hospital
• Angiooedema • Acute meningococcacaemia
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