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Dermatological Emergencies - Coggle Diagram
Dermatological Emergencies
History
Durration, progression, location
Thorough
medication hx
Past mhx
Atopy
Fhx, shx
Atopy
Sun exposure - aggrevating factor
Sexual hx
Exam
Head to toe in a gown
Good lighting
All skin and
mucosal
surfaces
Hair nails and scalp
Erythroderma (Exfoliative Dermatitis)
Def
PResence of erythema abd desquamation involving more than 90% of skin surfaces
Causes
Inflammatory skin conditions
Top 5
Psoriasis
Eczema
Drug eruptions
Lymphoma
Iodiopathic
Others
Neoplasia
Connective tissue disorder
Infection - scabies
Immunobullous 0 Pemphigus vulgaris, BP, Hailey-Hailey, Darier
Lichen planus
Sarcoidosis
Graft vs host disease
Primary Vs Secondary
Primary
Erythema initially on trunk - within few days to weeks extends to involve whole skin surface
Followed by desquamation
Secondary
Generalisation of previous localised skin disease
Acute vs Chronic
Drugs
Should settle within 2-6 weeks of stoppping
Diuretics
Anti-epiletics
Sulfa drugs
Isoniazid
Gold
NSAIDs
Catopril
Homeopathy / herbs
Allopurinol
Abx
Anti-malarials
Anti-psychotics - lithoum
DDx
Psoriasis
Atopic dermatitis
Drug eruption
Cutaeous T-cell lymphoma
Pityriasis rubra pilais
Clinical Features
? Underlying skin disease
RApidly confluent erythema within 12-48hr
Fever, rigors, malaise
Hypo > hyperthermia
Scale after 2-6 days
Pruritis in 90%
Lichenification
Lymphadenopathy
Oedema of lowe limbs
Complications / Sequelae
Thermoreregulation
thrombosis
Haemodyndamic dysfx
Enteropathy
Electrolyte distrubance
Infx
Hypoalbuminaemia
Non-scarring alopecia ie Telogen Effluvium
Ectropion
Dystrophic nails
Shiny, discoloured, subungal hyperkeratosis, Beau's lines, spliter haemorrhages
Multiple seborrhoeic keratoses
Investigations
Bloods
ROuting, haematinics
Cultures
+/- LDH
+/- Auto-antibody screen ,ESR
Bedside
MSU
Skin swab +/- throat swab
ECG
Imaging
CXR
Other
Skin biopsy
Managment
Admit
Fluid balance
Temp regulation
Review medicaitions - cease if non-essential
Tx
Topical
Emollients
Soap substitutes
Steroids
Systemic
Oral steroids - not in Psoriasis
Antihistamine
Tx infx
Thrombophylaxis
Steroid sparing agents / Immunosuppressants / biologics
Medicat tx
Dietician review
Tx underlying condition
Pityriasis Rubra Pilaris
Def
Papulosquamous disorder
Clinical
Can lead to erythroderma
Often starst o head and neck region and extends cepahlly caudally
Salmon / Orange red colour
Islands of sparing
Follicular papules
Waxy keratoderma
Epid
1st-2nd decade of life
6th decade
Pustular Psoriasis
Types
Generalised
Acute
Chronice
Localised
Palmar plantar pustulosis
Acrodermatitis continuea of Halopeu
Generalised Pustular Psoriasis
Epidemiology
Uncommon variant
Many cases idiopathic
Clinical features
Widespread erythematous sterile pustules
Predominantly neutrophilic infiltrate on cellular level
Severe inflammatory diease that requires hospitalisation and aggressive therapy
Risk factors
Infx
Rapid withdrawal of steroids
Pregnancy
Topical irritants - tar / anthralin
Warning Signs
Burning
Tnderness
Abrupt onset high fever and severe malaise
Pre-existing plaques become erythematous with superimposed pustules
Confluent erythema and crops of pustulation spreads to involve normal skins - esp flexures and genitalia
Prognosis
Remission in days - weeks
High risk of relaps
Trigger
Irritating topical therapy ( Tar / Dithranol)
Infx
Pregnancy
Hypocalcaemia
Drugs
Withdrawal of systemic steroids / potent topical steroids
Withdrawal of ciclosporin
Eg Salicylates, Lithium , terbinafine
Complications / Sequelae
Low albumin, calcium
Cholestatic jaundice
DVT
Secondary infection - staph aureaus
Inflammatory polyarthritis
Amyloidosis
Obstetric complications
Telogen Effuvium
Management
As per erythroderma
Withdrawal / treat triggers
Admit
Bed rest
Thromboprophylaxis
Thermoregulation
Correct electrolyte distrubance
Fluid / nutritional support
Analgesia
Antihistamines
Tx
Topical
Emollients
Steroids - moderate potency !
Tar and dithranol are C/I
Systemic
Acitretin - avoid in childbearing
MXT / Ciclosporin / biologics
Spesolimba 1st licensed atx for Generalised Pustular Psoriasis
MOA
Blocks key inflammatroy pathway in GPP by targeting IL-36 receptor
Unregulated IL-36R signalling leads to a neutrophilic inflammatory response in GPP
IL-36 agonsits and antagonists work together to regulate the IL-36 pathway, ensuring a balanced immune response
Wehn IL-36 agonists are over-expressed of the IL-36 receptor antagonist is not fx properly , leads to excessive inflammation and the development of sterile pustules , characteristic hallmark of GPP
Missing notes
Dxx
AGEP - Acute Generalised Exanthematous Pustulosis
Widespread HSV
Folliculitis
Palmar Plantar Pustulosis
Def
Chronic, relapsing eruptiob limited to palms and soles
Clinical features
Numerous typical sterileyellow, deep-seated pustules that evolve into dusky-red crusts
Stinging, burning, then itching
Rarely may develop elsewhere
Epi
More common in women
Triggers
Infx
Stress
Maybe smoking
Acrodermatitis Continue of Halopeau
Clinical features
Pustules on fingertips and nailbed
Often with nail dystrophy and lossssssssssss
Erythrodermic Psoriasis & Psoriatic Arthritis
Psoraitic Arthritis and /Nail Dystrophy
Serious Cutaneous Adverse Drug Reactions (SCAR)
DRESS
Drug reaction with eosinophilia and systemic Symptoms
Triad
Fever
Rash
Internal organ involvement
Hepatitis
Lymphadenopathy
Nephritis
Penumonitis
Haematological disturbance
Myocarditis
Thyroiditis
Atypical lymphocytes
Eosinophilia
Disease progress
Onset 1-8 weeks
Prodrom
Fever
Malaise
Pharyngitis
Clinical Features
Rash
Exfoliative
Erythrodermic
Pustular
SJS
TENS
FAce / upper trunk and extremities
Morbilliform
Facial Oedema
Eoisinophilia in 90%
Atypical Lymphocytosis n 40%
Deranged LFTs
Mortality 8%
Offending Drugs
Minocycline
Allopurinol
HAART
Terbinafine
Anticonvulsants
Sulfas
Trimethoprim
Management
Stop drug
Consult as per organ involvement
Steroids - taper slowly
Topicals
Emollients
Steroids
etc
Stephen Johnson Syndrome
Stephen Johnson Syndrome / Toxic epidermal Necrolysis overlap
Toxic Epidemermal Necrolysis
Erythema Multiforme
Cause
HSV
DIsease progression
Self limited
Potentially recurrent
Abrupt onset
Clinical features
Symmetrical target lesions, may boebnerise
Pain
Pruritis
Blistering occasionally
+/- mucous membrane involvement
Types
Minor
Acral distribution
Little or no mucosal involvement
Self limiting within 2 weeks
Major
Beyond acral distrubtion
Mucosal involvement
Systemic symptoms
Urticaria v Erythema Multiforme
Urticaria
CEntral zone normal
Transient esions lasting hours
New lesions daily
Oedema
Erythema Multiforme
Target lesions - centreal zone dusky and crusted
Fixed for days
All appear in first 72hrs
No oedea