Dermatology is not exactly my forte, for me all rashes do look the same. However. there are 4 patterns of dermatologic emergencies worth to remember.
- Skin pain
- “red skin”
- A case review of 56 paediatric patients with erythromderma, 45% progressed to shock.
- Erythroderma is similar to skin burn, a lot of fluids are lost from the skin surface.
– Erythrodermic psoriasis
– Exfoliative Dermatitis, pityriasis rubra pilaris
– Drug induced (morbilliform drug eruption, AGEP, DRESS)
– Infection (TSS)
Pityriasis rubra pilaris: reddish-orange coloured scaling patches with well defined borders, spared skin areas are called islands of sparing
Cutaneous T cell lymphoma when it affects the whole body is called Sezary syndrome (red skin syndrome)
- Normally CTCL (Mycosis fungoides – in patch stage
- Sezary syndrome
- Erythroderma + shock
- Traditional associated with tampon use
- S.aureus is the usual cause
- The exotoxins are the culprit of the erythroderma, therefore clindamycin is needed (in addition to antistaphylococcal penicillins); similar to SSSS
Drug induced – common culprits: sulfa, seizure (carbamazepine, phenytoin, lamotrigine), cillins, erythromycin, allopurinol
- Morbilliform drug eruptions
- DRESS (Drug Reaction with Eosinophilia and Systemic Symptoms)
– Morbilliform eruption (80%); exfoliative dermatitis.
– Erythroderma in 10%
– Lymphadenopathy (75%)
– Hematological abns (eosinophilia, thrombocytopenia, anemia)
– Hepatomegaly, abnormal LFT
– Multi-organs failure
- AGEP (Acute Generalized Exanthematous Pustulosis)
– Fever + multiple pustules on a widespread erythematous background.
– Predominantly affects the main body folds and upper trunk.
Desquamation – normally with positive Nicholsky sign and Arboe-Hanson sign (bulla spread sign)
- BURNS ! **
– Burns in kids can be due to accidents (i.e playing with fire or accidently got burned) or non-accidental (i.e abuse)
- Erythema multiforme major – involves mucous membrane
– Typical target lesion (also called iris lesion) of erythema multiforme has a sharp margin and three concentric colour zones: centre is dusky with a blister or crust, next ring is a paler pink and is raised due to oedema (fluid swelling), outermost ring is bright red.
– Atypical target lesions show just 2 zones and/or an indistinct border.
- SJS, TEN
– SJS involves <10% of BSA
– TEN involves >30% of BSA
– SJS-TEN overlap: 10-30% of BSA
- SSSS (Staphyloccal Scalded Skin Syndrome)
- Kawasaki disease: normally a late finding during convalescent phase
– Cellulitis, especially hand cellulitis because compartments are interconnected, infection can spread around.
– Necrotizing fasciitis (type I due to C.perferingens, type II due to S.pyogenes) –> pain out of proportion to extent of the rash
– Perineal NF: Fournier’s gangrene
- Compartment syndrome: post trauma, the skin feels tense, pain is the earliest symptom
Petechiae & purpura
- Infection (look for star-like configuration), normally below the nipples
– S.aureus, S.pyogenes sepsis
– Dengue, leptospirosis (petechiae instead of purpura)
– Purpura above the nipples can be benign due to barotrauma and coughing
- Vasculitis: normally with palpable purpura
– ANCA related (microscopic polyangiitis) and non-ANCA related small vessel vasculitis (eg malignancy and drug related)
– Henoch-schonlein purpura, cryoglobulinemia
– Atheroembolic disease
- Hematological: ITP, coagulopathy (HUS/TTP, DIC)