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ER44 Emergency Medicine
Dermatologic Emergencies Toronto Notes 2019
■ vesicobullous lesions
■ Erythema Multiforme (EM)
◆ immunologic reaction to herpes simplex
◆ viral prodrome 1-14 d before rash
◆ target lesion: central grey bulla or wheal surrounded by concentric rings of erythema and
normal skin
B. Discrete Lesions
■ pyoderma gangrenosum
◆ often associated with IBD, rheumatoid conditions, leukemia, and monoclonal gammopathies. ◆ often occurs in arms, hands, feet, or perineal region
◆ usually begins as painless macule/vesicle pustule/bulla on red/blue base sloughing, leaving a
gangrenous ulcer
■ disseminated gonococcal infection
◆ see Dermatology, D32
◆ fever, skin lesions (pustules/vesicles on erythematous base ~5 mm in diameter), arthritis (joint swelling and tenderness), and septic arthritis (in larger joints, such as knees, ankles, and elbows)
◆ most commonly in gonococcus-positive women during menstruation or pregnancy
◆ skin lesions usually appear in extremities and resolve quickly (<7 d) ■ meningococcemia
◆ flu-like symptoms of headache, myalgia, N/V
◆ petechial, macular, or maculopapular lesions with grey vesicular centres
◆ usually a few millimeters in size, but may become confluent and hemorrhagic
◆ usually appear in extremities, but may appear anywhere
◆ look for signs of meningeal irritation: positive jolt accentuation test, Brudzinski, Kernig.
History and Physical Exam
• determineonset,course,andlocationofskinlesions
• fever,jointpain
• associatedsymptoms:CNS,respiratory,GU,GI,renal,liver,mucousmembranes • medications,sexualencounters,livingenvironment,occupationalexposures
• vitals,physicalexambasedonrelevanthistory
Investigations
• immediateconsultationifpatientunstable
• case-dependent,consider:CBC,electrolytes,Cr,AST,ALT,ALP,bloodculture,skinbiopsy,serum
immunoglobulin levels (serum IgE)
Management
• general:judiciousIVfluidsandelectrolytecontrol,considervasopressorsifhypotensive,preventionof infection
• determineifadmissionandconsultneeded:dermatologyorinfectiousdiseases
• specificmanagementisdeterminedbyetiology
■ SSSS, TSS, DGI, and meningococcemia ◆ IV antibiotics
■ EM, SJS, and TEN
◆ stop precipitating medication
◆ fluids
◆ symptomatic treatment: antihistamines, antacids, topical corticosteroids, systemic
corticosteroids (controversial), prophylactic oral acyclovir, consider IVIG, plasmaphoresis ◆ TEN: debride necrotic tissue
Disposition
• mostcaseswillrequireurgentcareandhospitalization
• SJS&TEN:earlytransfertoburncentreimprovesoutcome
Thorough dermatologic examinations are required; examination of asymptomatic skin may identify more lesions; ensure adequate draping during dermatologic examinations
SJS = <10% of BSA SJS/TEN = 10-30% BSA TEN = >30% BSA