Approach to the Unknown Rash

Transcription

1 (+)Heather M. Murphy-Lavoie, MD Assistant Residency Director and Assistant Professor, Louisiana State University, Section of Emergency Medicine, New Orleans, Louisiana Approach to the Unknown Rash How do you approach the unknown rash? Knowing how to identify and classify a skin lesion is an essential component in developing a systematic and organized approach to any lesion. The speaker will present guidelines for the proper diagnosis of various dermatologic conditions using case presentations to illustrate these concepts. Describe dermatologic conditions by the type of lesion and the distribution area. Develop a systematic approach to skin lesions. Identify dermatologic conditions requiring emergency interventions. Discuss appropriate differential diagnoses, treatments, and dispositions for patients with dermatologic complaints. TH-267 Thursday, October 8, :00 AM - 9:50 AM Boston Convention & Exhibition Center (+)No significant financial relationships to disclose

2 Approach To The Unknown Rash By Heather Murphy-Lavoie, MD I. Introduction a. There are more than 3000 dermatologic diagnoses b. Approximately 5% of ED visits are for a dermatologic complaint c. Objectives i. Describe dermatologic conditions by the type of lesion and the distribution area. ii. Develop a systematic approach to skin lesions. iii. Identify dermatologic conditions requiring emergency interventions. iv. Discuss appropriate differential diagnoses, treatments, and dispositions for patients with dermatologic complaints. II. III. History a. Age b. Duration c. Associated symptoms i. Itching ii. Fever iii. Pain d. Travel/Location e. Sick Contacts f. Past Medical History g. Medications new h. Menstrual history i. Sexual history j. Vaccinations Physical Exam a. Vital signs i. Hypotension ii. Tachycardia iii. Fever iv. Mental Status Change b. Distribution

3 i. Central ii. Peripheral iii. Flexural surfaces iv. Intertriginous v. Dermatomal vi. Neurotic Excoriation vii. Extensor surfaces viii. Mucosal surface involvement c. Appearance i. Scaly/Moist ii. Color iii. Hyper/hypopigmented iv. Honey Crusted v. Umbilicated vi. Blanching vii. Palpable d. Wood s Lamp i. Microsporum Tinea Capitus (green) ii. Erythrasma (coral red) IV. Algorithms a. Erythematous b. Maculopapular c. Petechiae/Purpura d. Vesiculo-bullous

4 ALGORITHM ERYTHEMATOUS RASH ERYTHEMATOUS RASH YES NIKOLSKY S SIGN NO FEBRILE Staph SSS (child) TEN (adult) AFEBRILE TEN (adult) FEBRILE Toxic Shock (mucous membranes) Kawasaki Syndrome (child, hands) Scarlet Fever (sand paper) AFEBRILE Anaphylaxis Scombroid Alcohol Flush Differential Diagnosis: Staph SSS = Staphylococcal Scaled Skin Syndrome - children, IV Penicillinaseresistant penicillin, IV Fluids, local wound care Toxic Shock Synd= Toxic Shock Syndrome - look for source (eg. a tampon) and remove, IV Penicillinase-resistant penicillin, IV fluids, supportive care, hospital admission Kawasaki= Kawasaki s Disease - children, mucous membranes, lymph nodes, hands and feet, elevated platelet count, treat with immune globulin, aspirin Scarlet Fever - children, sandpaper-like rash, strawberry tongue, tonsillitis, treat with penicillin TEN = Toxic Epidermal Necrolysis - adults, drug reaction- often sulfa, treatment remove offending source, wound care, IV fluids, admit to burn center Anaphylaxis - treat with steroids, antihistamines, H2 blockers and possibly epinephrine for the most severe cases Scombroid - history of eating fish recently, treat with antihistamines, usually selflimited Alcohol flushing - history of alcohol ingestion, prior episodes, no itching, normal vitals, no fever, self-limited

5 ALGORITHM MACULOPAPULAR RASH MACULOPAPULAR RASH CENTRAL PERIPHERAL FEVER / ILL? FEVER / ILL? YES NO YES NO Viral Exanthem Lyme Disease (erythema migrans) Drug Reaction Pityriasis (herald patch) TARGET LESIONS LESION YES NO FLEXO EXTENSOR Stevens-Johnson TEN Erythema Multiforme Meningococcemia Rocky Mountain Spotted Fever Syphilis Lyme Disease (erythema migrans) Scabies Eczema Psoriasis Viral Exanthem - Measles, Rubella, Fifths, etc, self-limiting, supportive care Lyme Disease - Tick bite, erythema migrans, arthralgias, headache, doxycycline Pityriasis - scaly lesions, herald patch, Christmas tree pattern, treatment includes: UV light, moisturizing lotion, Aveeno, antihistamines Drug Reaction - remove the drug, symptomatic treatment Stevens-Johnson Syndrome - mucosal involvement, remove drug/treat illness, supportive therapy, hospital admission EM = Erythema Multiforme - treat illness/stop drug, supportive care, topical steroids and outpatient follow-up for minor cases Meningiococcemia - ill appearing, mental status change, lumbar puncture, ceftriaxone, isolation, treat close contacts, hospital admission RMSF = Rocky Mountain Spotted Fever - tick bite, endemic area, headache, arthralgias, doxycycline Scabies - excoriated burrows, itches worse at night, permethrin

6 ALGORITHM VESICULO-BULLOUS RASH VESICULO-BULLOUS RASH FEBRILE AFEBRILE DIFFUSE LOCALIZED DIFFUSE LOCALIZED Varicella / Chicken Pox Small Pox Disseminated GC Purpurpa Fulminans / DIC Necrotizing Fasciitis Hand Foot Mouth Bullous Pemphigus Pemphigus Vulgaris Contact Dermatitis Herpes Zoster Dyshidrotic Eczema Burns Differential Diagnosis: Varicella/Chicken Pox excoriated lesions in multiple stages, starts centrally, isolate, rare hospitalization, symptomatic treatment, antipyretics (not Aspirin) Small Pox all lesions in one stage, more peripheral distribution, isolate, notify office of public health and CDC Disseminated GC= Gonococcemia - purple vesicles, sparce, peripheral, associated urethritis/cervicitis/septic arthritis, ceftriaxone Purpura Fulminans/DIC = Disseminated Intervascular Coagulation - treat the underlying cause, fresh frozen plasma, platelet transfusions, ICU admission Necrotizing Fasciitis surgical emergency, debridement, IV anti-streptococcal broad spectrum antibiotic, hyperbaric oxygen therapy Hand, Foot and Mouth Disease children, vesicles on palms, soles and in mouth, self-limited, symptomatic treatment Bullous Pemphigus -chronic autoimmune blistering, elderly, usually benign, steroids Pemphigus Vulgaris mucous membrane involvement, much higher mortality than Bullous Pemphigus, steroids, admission Zoster acyclovir, analgesia, steroids Contact Dermatits - symptomatic treatment, long taper of steroids for severe cases Dyshidrotic Eczema - topical steroids

7 ALGORITHM PETECHIAL/PURPURIC RASH PETECHIAL / PURPURIC RASH FEBRILE & TOXIC AFEBRILE & NON-TOXIC PALPABLE NOT PALPABLE PALPABLE NOT PALPABLE Meningococcemia Disseminated GC Endocarditis RMSF HSP Purpurpa Fulminans / DIC TTP Cutaneous Vasculitis ITP Differential Diagnosis: Meningiococcemia - ill appearing, mental status change, lumbar puncture, ceftriaxone, isolation, treat close contacts, admission Disseminated GC= Gonococcemia - purple vesicles, sparce, peripheral, associated urethritis/cervicitis/septic arthritis, ceftriaxone Endocarditis new murmur, vegetations on valves, positive blood cultures, IV vancomycin and gentamicin pending culture results RMSF = Rocky Mountain Spotted Fever - tick bite, endemic area, headache, arthralgias, doxycycline HSP = Henoch Schonlein Purpura children, associated arthralgias, hematuria and GI symptoms, supportive therapy TTP= Thrombotic Thrombocytopenic Purpura - low platelet count, ICU admission, treat underlying cause, plasmapheresis, splenectomy, selective transfusion, NO platelets Vasculitis treat the underlying process if possible, may require steroids and/or other anti-inflammatory agents ITP Idiopathic Thrombocytopenic Purpura - transfuse platelets if bleeding or less than 5000/mm /mm3, emergent Hematology consultation

8 V. Summary With the type of lesion, distribution, and whether or not the patient is ill, one can narrow the diagnosis down to one or two diagnoses in many cases. THE VERY YOUNG Staph SSS, Kawasaki s disease, viral exanthem, meningococcemia TOXIC necrotizing fasciitis, meningococcemia, TEN, SJS, TSS, RMSF, TTP DIFFUSE ERYTHEMA staph SSS, staph TSS, strep TSS, TEN THE VERY OLD pemphigus vulgaris, sepsis, TEN, SJS IMMUNOSUPPRESSED necrotizing fasciitis, meningococcemia, endocarditis, herpes zoster, sepsis PETECHIAE / PURPURA meningococcemia, endocarditis, TTP, ITP vasculitis, DIC, RMSF MUCOSAL LESIONS HYPOTENSION EM major, TEN, SJS, meningococcemia, TTP, pemphigus vulgaris TSS, RMSF, TEN, SJS TEN = toxic epidermal necrolysis; SJS = Stevens-Johnson Syndrome, TSS = toxic shock syndrome, RMSF = Rocky Mountain spotted fever, SSS = scalded skin syndrome, DIC = disseminated intravascular coagulopathy, EM = erythema multiforme, TTP= thrombotic thrombocytopenic purpura VI. Appendix LESION single small diseased area RASH more extensive involvement MACULE circumscribed area of change without elevation PUSTULE circumscribed area containing purulence PAPULE solid raised lesion < 0.5 cm VESICLE circumscribed fluid-filled area < 0.5 cm NODULE solid raised lesion > 0.5 cm BULLA circumscribed fluid-filled area > 0.5 cm PLAQUE circumscribed elevated confluence of papules > 0.5 cm PETECHIAE small red / brown macules < 0.5 cm that do not blanche

9 a. More Definitions i. Erosion- loss of epidermis only ii. Ulcer- extends below epidermis to involve dermis and subcutaneous tissue iii. Fissure- linear split in skin iv. Excoriation- linear superficial erosions or crusts due to scratching v. Wheal- soft smooth, raised papule, light pink (eg. Urticaria) vi. Burrow- linear S shaped papule 3-5mm long vii. Purpura- > 0.5cm does not blanch with pressure, red/purple macules REFERENCES: 1. Adams JG et al. Emergency Medicine. Saunders Elsevier, Philadelphia, Ashton, R. and B. Leppard. Differential Diagnosis in Dermatology. 3 rd Ed. Radcliffe Publishing, United Kingdom Baroni, A., et al. Vesicular and Bullous disorders: Pemphigus. Dermatol Clin 25 (2007) Bassam Z, et al. Pemphigus Vulgaris. on web at 5. Braunwald, et. al. Harrison¹s Principles of Internal Medicine. 15 th Ed. McGraw Hill, New York, Buckingham SC, et al. Clinical and Laboratory Features, Hospital Course, and Outcome of Rocky Mountain Spotted Fever in Children. J Pediatrics 2007; 150: Carr, D., Houshmand, E., and M. Heffernan. Approach to the Acute, Generalized, Blistering Patient. Semin Cutan Med Surg 26: , Chan, L. Bullous Pemphigoid. Emedicine (2008) Chapman AS, et al. Rocky Mountain Spotted Fever in the United States, Ann. N.Y. Acad. Sci. 2006; 1078: Chia, F., and K.P. Leong. Severe Cutaneous Adverse Reactions to Drugs. Curr Opin Allergy Clin Immunol 7: , Fleischer, A., et. al. Emergency Dermatology: A Rapid Guide to Treatment. McGraw Hill, New York, Ghatan, H. Dermatologic Differential Diagnosis and Pearls. 2 nd Ed. Parthenon Publishing, New York, Ghislain, P.D., and J.C. Roujeau. Treatment of Severe Drug Reactions: Stevens-Johnson Syndrome, Toxic Epidermal Necrolysis and Hypersensitivity Syndrome. Derm Online J, vol 8 (1): 5 pp Harwood-Nuss, A., et. al. The Clinical Practice of Emergency Medicine. 2 nd Ed. Lippincott-Raven, Philadelphia, Hom, C. Vasculitis and Thrombophlebitis. Emedicine (2008) Mukasa, Y., and N. Craven. Management of Toxic Epidermal Necrolysis and Related Syndromes. Postgrad. Med. J. 2008: 84:

10 17. Nguyen, T and J Freedman. Dermatologic Emergencies: Diagnosing and Managing Life-Threatening Rashes. Emergency Medicine Practice, Volume 4 (9) September Sauer, G., and J. Hall. Manual of Skin Diseases. 7 th Ed. Lippincott-Raven, Philadelphia, Slaven, EM, et al. Infectious Diseases: Emergency Department Diagnosis and Management. McGraw Hill, New York, Tintinalli JE, et al. Emergency Medicine: A Comprehensive Study Guide. 6 th Edition. McGraw Hill, New York, Wolf, R., et al. Drug Rash with Eosinophilia and Systemic Symptoms vs. Toxic Epidermal Necrolysis: the Dilemma of Classification. Clin Derm (2005) 23, Margileth, A. Scaled Skin Syndrome: Diagnosis, Differential Diagnosis, and Management of 42 Children. South Med J. (1975) 68: Yamamoto, L. Kawasaki Disease. Ped Em Care. (2003) Levi, M. Disseminated Intravascular Coagulation. Crit Care Med. (2007) 35: Levi, M. Novel Approaches to the Management of Disseminated Intravascular Coagulation. Crit Care Med. (2000) 28: S20 S Sarode, R. Atypical Presentations of Thrombotic Thrombocytopenic Purpura: A Review. J Clin Apheresis. (2009) 00: Bastuji Garin S, Fouchard N, Bertocchi M, Roujeau JC, Re vuz J, Wolkenstein P. SCORTEN: a severity of illness score for toxic epidermal necrolysis. J Invest Dermatol 2000;115: Mittimann, N, et al. IVIG for the Treatment of Toxic Epidermal Necrolysis. Skin Therapy Lett Feb;12(1):7 9.

11 UNKNOWN RASH SELF-ASSESMENT