Dermatologic Emergencies

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.

  1. Erythroderma
  2. Desquamation
  3. Skin pain
  4. Petechiae/purpura/ecchymosis

Erythroderma

  • “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.
  • Ddx:
    – Erythrodermic psoriasis
    – Exfoliative Dermatitis, pityriasis rubra pilaris
    – Drug induced (morbilliform drug eruption, AGEP, DRESS)
    – Infection (TSS)
    – Lymphoma

Erythrodermic psoriasis

Exfoliative dermatitis

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
    Mycosis fungoides
  • Sezary syndrome

TSS

  • 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)

Nicholsky sign

Arboe-Hansen 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

Skin pain

  • Infection
    – 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
    – RMSF
    – S.aureus, S.pyogenes sepsis
    – Meningococcemia
    – 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)
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