DERMATOLOGIC EMERGENCIES

(KEGAWATDARURATAN KULIT)

Marta Dwi Rifka

Dermatologic complaints account for approximately 5%
of all ED visits.(1)

Dermatologic Emergencies

Acute skin failure

Loss of thermoregulatory/metabolic/infection control

mechanism of the skin
Overview
Recognation &
clinical features

Aetiology &
Management
patophysiology

Complication Diagnosis
Skin lesion type
Primary:
Macule
Papule
Nodule
Plaque
Pustule
Vesicle
Bulla
Petechiae
Purpura

Secondary :

Scales: Excess dead epidermal cells produced

by abnormal keratinization; scaling in
sheets is desquamation

Erosion
Excoriation
Ulcer
Crust
Lichenification
Atrophy
Macule Patch
Papule Nodule

pustule
Papul Plaque

Vesicle Bulla
Petechie, purpura
 STEVENS-JOHNSON SYNDROME AND TOXIC EPIDERMAL
NECROLYSIS

BULLOUS DISORDERS PEMPHIGUS

STAPHYLOCOCCAL SCALDED SKIN SYNDROME

ERYTHRODERMA/EXFOLIATIVE DERMATITIS

URTICARIA AND ANGIOEDEMA

 Steven Johnson Syndrome (SJS)
Characteristics:
Extensive necrosis & detachment of epidermis

Etiology:
Drugs:
sulfonamide, carbamazepin, phenobarbitone, carbamazepine, sodium
valproate, allopurinol, oxicam NSAIDS, diclofenac, lamotrigine, nevirapine

Patophysiology:
Cell mediated cytotoxic reactions againts keratinocyte massive
apoptosis epidermal necrosis detachment of epidermis

Anamnesis:
History of taking the drug 4-30 days (8 weeks) before the appearance of
clinical symptom.
Non specific symptom may precede the mucocutaneous lesion by 1-3
days.
Skin lesion:
Early eruption:
erythematous dusky red
macules

Mucous membrane
Advance eruption: involvement: at least
blisters, epidermal at 2 sites buccal,
detachment ocular, genital mucosa

Full blown epid necrolysis:

large erosive areas

Nikolsky sign (+)

Extracutaneous symptoms
High fever, pain, weakness
Dyspnea, bronchial hypersecretion, hemoptysis,
expectoration of bronchial mucosal cast
Melena, colon perforation
Hematuria,proteinuria
Classification
According to the total area in which epidermis
detached:
< 10% BSA: SJS
10-30% BSA: SJS/TEN overlap
> 30%: TEN (Toxic Epidermal Necrolysis)
Toxic Epidermal Necrolysis (TEN)

The total area in which epidermis

detached: > 30% BSA

The mortality rate:

SJS: 5-12%
TEN: >30%
Laboratory Test
Anemia, mild leucocytosis & trombocytopenia
BGA, serum bicnat <20 mM poor prognosis
Electrolyte imbalances
Hypoalbuminemia, hypoproteinemia
Raised blood creatinin & BUN level
Hyperglycemia
Complication
Sepsis
Multysystem organ failure
Late ophthalmic complication: fibrosis, entropion,
trichiasis, symblepharon
Management oF SJS and TEN

Cessation of the suspected drug

ICU
Fluid and electrolyte management
Temperature control environment temperature 28 -30C
IV or Nasogastric nutrition
Skin,eye and mouth care
Treatment of secondary Infection
Corticosteroid
Doses up to 2-2,5 mg/BW/day of IV prednisone in divided doses
Fluid Management
Ringers lactate

Volume requirements are given by:

Skin area affected x body weight x 3 ml.

2/3 of the thermal burn requirement

Given over the first 24 hour period.

Bullous Disorders
Pemphigus
Characteristics:
Autoimmune blistering diseases of skin &
mucous membranes

Etiology:
Autoimmune reactions

Patophysiology:
Immunoglobulin G direct againt the cell surface of
keratinocytes separation of edipermal cells from
each other acantholysis intraepidermal blistering

Skin lesions:
Erosion/ulceration of oropharynx
stomatitis
Cutaneous lesions: blisters, ruptured
easily leaving erosion.
Laboratory Test
Routine blood count, serum chemistries
Skin biopsy for hystology
Immunofluoresence

Complication
Sepsis

Management
Skin & mouth care wound dressing
Treatment of secondary Infection
Corticosteroid
Staphylococcal Scalded Skin Syndrome
(SSSS/S4)

Etiology:
Exfoliative toxin of S. aureus

Patophysiology:
Exfoliative toxin (serin proteases) bind to cell
adhesion molecule desmoglein I and cleave it loss of
cell-cell adhesion epidermolysis between strat
spinosum strat granulosum

Skin lesions:
Erythema local or generalized
Tenderness
Bullae very thin walled flaccid bulae
Exfoliation
Nikolsky sign (+)
Laboratory Test
Routine blood count, serum chemistries
Skin biopsy for hystology
Immunofluoresence

Complication
Fluid & electrolyte disturbances
Sepsis

Management
Fluid & electrolyte
Intravenous antibiotic
Topical mupirosin ointment
Skin care
Differential Diagnosis
Steven Johnson Syndrome Pemphigus Staphylococcal Scalded Skin Syndrome

SJS Pemphigus SSSS

Epidemiology at any age 40-60 years old infants , children

Etiology drug Autoimmune S. Aureus

Patophysio Cytotoxic reaction Autoimmune reaction Exfoliative toxin

Target lesions Subepidermal blistering Suprabasal blistering Subcorneal blistering

Mucous membrane At least 2 (>>severe) 1 (-)

involvement
Progression rapid slowly rapid
 Eksfoliative Dermatitis /Erythroderma
Characteristics:
Diffuse erythema & scaling of skin involving >90% BSA

Etiology:
Psoriasis
Atopic dermatitis
Other spongiotic dermatoses
Drug hypersensitivity reaction
Cutaneous T-Cell Lymphoma
Idiopathic (20%)

Patogenesis:
related to the patogenesis of underlying disease
Skin lesions:

Erythematous patches generalized red erythema with a

shiny app.
White or yellow scalling
Palmoplantar keratoderma
Ectropion, epiphora
Related physical findings
Thermoregulatory disturbance hyperthermia, hypothermia, feeling
chilly.
Increased blood flow to the skin & fluid loss due todisrupted
epidermal barrier tachycardi
Peripheral pedal or pretibial edema
Facial edema (rare)
Lymphadenopathy
Hepatomegaly (in drug induced ED)
Splenomegaly (associated with lymphoma)
Laboratory Test
Leucocytosis, lymphocytosis, eosinophylia, increased Ig E,
elevated ESD
Electrolyte abnormality
Elevated creatinin level
Decreased serum albumin

Complication
Fluid & electrolyte imbalances
Thermoregulatory disturbance
High out put cardiac failure
Renal failure
Secondary Infection
Hypoalbuminemia
Management

First line
Fluid & electrolyte replacement
High calorie high protein dietary, folate supplementation
Antihistamin
Systemic antibiotic if secondary infection
Diuretics for peripheral edema
Environment should be warm & humid
Emolient, low potency topical corticosteroid

Second line
Corticosteroid, methotrexate, etc
 Acute Urticaria & Angioedema
Etiology:
Drug, food , infection

Patophysiology:
Mast cell degranulation & histamine release

Edema:
superficial dermis urticaria
deep dermis/subcutaneous/submucosal angioedema

Skin lesions:
Wheals, angioedema
Itchy/pruritus
Management
Antihistamin: diphenhydramine 25-50mg (iv/im)
Corticosteroid : methylprednisolone 40-60 mg/day, for 3
days tapper by 10 mg/day
Cooling moisturisers
Identification & elimination of endo/exogenous causes

Epinephrine generalized uricaria, severe pruritus,

accelerate angioedema, laryngeal edema
Epinephrin 1:1000 0,01 mg/kg BW or 0,3 mg (im)
THANK YOU