Don’t be Rash! How to approach the undifferentiated lesion

GENINE SICILIANO, MD

PGY 3, EMERGENCY MEDICINE

SENIOR GRAND ROUNDS

AUGUST 28TH, 2014

The Curse of theUnknown Lesion

Snapshot cartoons at jasonlove.com

Goals

Review EM Dermatology Basics How to describe a rash/talk to our derm consultants

Algorithmic approach to differential diagnosis of the unknown lesion

Quickly recognize toxic from non-toxic rashes

Focus on 3 rare dermatology emergencies you can’t miss

Case 1 35 yo M, h/o psoriasis,

tachycardic, ill appearing

-This covers 90% of his body

http://psoriasisfreetips.com/wp-content/gallery/photos-pustular/pustular-psoriasis-pictures-3-508x338.jpeg

Case 2 Elderly gentleman brought back for fever, tachycardia

Picture: P Mohite, A Bhatnagar. A Case Of Fournier's Gangrene Reconstructed By Pedicle Thigh Flap. The Internet Journal of Plastic Surgery. 2006 Volume 3 Number 1.

Dermatology for the Emergency Physician

Must know:How to describe rashes Basic differentialToxic vs non-toxic rashBasic management/resuscitationWhen/how to talk to your consultant

Why important?5% All ED visits

Step 1 Talk the Talk

Morphology

Table from Nguyen et al.

Morphology

Table from Nguyen et al.

Step 2: “Get Naked” PolicySkin Exam

MorphologyArrangementDistribution/Pattern ExtentEvolutionary Change

No Excuses!

Step 3 – Build your differential

Picture from: http://hdw.eweb4.com/out/633579.html

Algorithmic Approach to Differential Diagnosis

Goal: Improve how we think about rashes and categorize them in our minds

Question 1: Rash morphology Question 2: Rash Distribution/Pattern Question 3: Sick or not Sick

Question 3: Sick or Not Sick

HistoryVitals are vitalLabs

RED FLAGS

Modified Lynch Algorithm

6 categoriesDiffuse erythematousNon-erythematousMaculopapularPetechial/PurpuricVeciulobullosPustular

Picture with permission from Dr. Walt Green

Modified Lynch Algorithm

Possible life- threatening

rash

Solid

Erythematous

Maculopapular Petechial/ Purpuric

Diffuse erythematous

Non-erythematous

Fluid-filled

Clear

Vesiculo-bullous

Pustular

5yoFever2 days

Image from DermnetNZ.org

4 yo w/ Fever, 3 days, well appearing

Image obtained from: http://www.sharinginhealth.ca/conditions_and_diseases/kawasaki.html. Author: Dong Soo Kim.

SolidErythematousMaculopapular

Maculopapular

Central

SICK: Viral Exanthem, Kawasaki*,

DRESS

NOT SICK: Drug rxn, pityriasis, tinea, viral

Peripheral

SICK: EM/SJS, Lyme, Meningococcemia*, Syphilis, early TSS,

RMSF

NOT Sick:

Scabies, Atopic

Dermatitis, psoriasis,

tinea

30yo, Fever, nausea, vomiting 2 days. Later developed stiff neck, HA

8yo, abdominal pain, rash.

http://www.vaccineinformation.org/photos/meni_mt002.jpg http://www.pediatricsconsultant360.com/sites/default/files/images/Screen%20Shot%202014-01-28%20at%2010.51.26%20AM.png

Solid ErythematousPetechial/Purpuric

Petechial/Purpuric

PalpableSick:

Meningococcemia*,

disseminated gonococcemi

a, endocarditis, RMSF, HSP

Not Sick: Autoimmune vasculitis,

HSP

Non Palpable

Sick: DIC, TTP

Not Sick: ITP

2 yo male in nursery with fever

25yo Male with HA, fever, tachycardia, nausea after leaving a restaurant

http://www.pediatricsconsultant360.com/sites/default/files/Screen%20Shot%202013-06-03%20at%2011.22.21%20AM.png

https://escholarship.org/uc/item/68h2w3wb/1.jpg

Solid Erythematous Diffuse Erythematous

Diffuse Erythematous

Sick

+ Nikolsky: SSSS/TEN,

DRESS

- Nikolsky: TSS, Kawasaki, Scarlet Fever, Erythroderma, Red man

syndrome , early nec fasc

Not Sick

Anaphylaxis, Scombroid, Alcohol

Flush

Solid Non-erythematous

Secondary SyphilisAnthraxVitiligo

http://manbir-online.com/grafics/Syphilis-hands.jpg

50yo w/ Flank pain 2 days, negative CT renal colic

65 yo with several days of painful, burning rash, now involving oral mucosa

http://www.medicalnewstoday.com/images/articles/154/154912/shingles-on-torso.jpg

http://classconnection.s3.amazonaws.com/445/flashcards/491445/jpg/bullous_pemphigoid_3_0505251328970809379.jpg

Fluid-filled Clear Vesiculo-bullous

Vesiculo-bullous

Diffuse

Sick: Varicella, Smallpox, Dissem

gonococcemia, DIC, TEN, PV

Not sick: PV,

BP

PeripheralSick: Nec Fasc, PV,

Hand-foot-

mouth

Not Sick: Contact dermatitis, Zoster, vesicular eczema,

burns

Fluid-filled Pustular

Bacterial FolliculitisGonorrheaGeneralized pustular

psoriasis

http://www.dermnetnz.org/acne/img/s/folliculitis5-s.jpg

Steroids

When?What kind?How long?

Topical Steroids Potency

Appropriate for rashToo weak= at risk for reboundBased on ability to induce vasoconstriction

Flourination Increases potencyAvoid in pregnancy

http://www.walgreens.com//images/drug/0151672128202.jpg

Topical Steroids- PotencyClass Potency Example

1 Highest Clobetasol (0.05%)

2 High Fluocinonide (0.05%)

3 High-Medium Triamcinolone (0.5%)

4 Medium Mometasone furoate (0.1%)

5 Medium-low Triamcinolone (0.1%)

6 Low Triamcinolone (0.025%)

7 Lowest Hydrocortisone (1%, 2.5%)

Oral SteroidsCaution!

DiabeticsImmunocompromisedHTNPUD

Taper vs short burst??

Journal of Family Practice, 2006

Other treatment options

AntihistaminesOther topicals

If it’s dry, keep it wet and if it’s wet, keep it dry

AntimicrobialsScabies, impetigo, candida, dermatophytes, etc.

Dermatologic Emergencies

Definition:

Acute skin loss leading to loss of thermoregulatory, metabolic, infection control sepsis

Dermatologic Emergencies you CAN’T afford to miss…

Fixed Drug Eruption Disseminated viral infections: VZV, HSV

EM/SJS/TEN – Note: not necessarily same spectrum

Anaphylaxis/angioedema BP/PV RMSF TTP, DIC

Meningiococcemia, Disseminated Gonoccoccal infection

Toxin mediated: SSSS, TSS Exfoliative Erythroderma: eczema, psoriasis

DRESS Syndrome Necrotizing Soft tissue infections

DRESS

http://meded.ucsd.edu/clinicalimg/drug_skin2.jpghttp://picture-cdn.wheretoget.it/7mtu9w-i.jpg

DRESS (Drug Reaction with Eosinophilia and Systemic Symptoms syndrome)

Definition: Severe adverse drug reaction with fever, rash, and internal organ involvement (liver= #1)

Causes:Mostly antiepileptics/mood stabilizers

Phenobarabital, carbamazepine, phenytoin, lamictal, sulfa, dapsone, modafanil, ? HHV6

DRESS Syndrome Pathophysiology: T cell mediated reaction (suspected), potential genetic predisposition

10% Mortality

Diagnostic Criteria:

RegiSCAR and Japanese consensus group

Management: Supportive, admission, support associated organ dysfunction

Regiscar Criteria

Add here

http://www.consultantlive.com/sites/default/files/cl/2123107.png

Case 1 - Generalized Pustular Psoriasis

Rare form of psoriasis in which most or all of the skin surface is involved with a scaly erythematous dermatitis (subset of erythroderma), puss filled blisters and plaques. Immune-mediated.

Diagnosis Febrile, systemically ill-appearing, leukocytosis. Triggering factors: drugs, infection, stress, steroids

Why important to ED Doc?Mortality – 8-20% worse with delayed diagnosis

Generalized Pustular Psoriasis

Complications: Metabolic (low albumin, Ca), amyloidosis, inflammatory polyarthritis, cholestatic jaundice, DVT, secondary staff infection.

Management: Withdraw provocative factors, admit, bed rest, fluid/electrolyte repletion, analgesia, antihistamines. Often need ICU.

Wound care: Bland emollients, wet dressings, mild-moderate topical steroids, systemic steroids in severe cases

Case 2: Necrotizing Soft Tissue InfectionsClassification: by microbial cause

Type I: Polymicrobial (aerobe and anaerobes) - 55-75%Common with DM, PVDClostridium less common in recent years

Type II: Group A Strep, StaphHealthy person with recent trauma, operation

?Type III: Vibrio Vulnificus

Necrotizing Soft Tissue Infections Risk Factors

Age, DM, alcoholism, PVD, CAD, RF, HIV/CA/immunocompromised, NSAIDs, IVDA, chronic ulcers/skin infections

Why Important?25-30% Mortality

Bacteremia = strong predictor of mortality

Exponentially worse with delayed diagnosis

Pathophysiology

Direct inoculation/invasion from injury site vs spontaneous

Bacteria proliferate invade subcutaneous & deep fascia release exotoxins tissue ischemia, necrosis, systemic toxicity

Spreads as fast as 1 inch/ hour Note: Early involvement causes little skin change

Signs/Symptoms & Diagnosis

PAIN out of proportion Fever, tachycardia Recent trauma/break in skin Cellulitic findings, edema Crepitus (only present 13-30% of time) Late findings: bronze/brownish discoloration, malodorous discharge, bullae

Labs: CBC, CMP, coags, cultures, blood gas Imaging: XR/CT

Picture from Dr. Walt Green

ED management EARLY DIAGNOSIS!!! Subtle findings in unclear cases Early Broad spectrum antibiotics

Rarely effective alone Fluids, transfusion as indicated Careful with pressors Early Surgical Intervention!!! Hyperbaric oxygen

Picture from Dr. Walt Green

?Pregunatas?

Conclusions Have a systematic, simple approach to the unknown rash

Start with “Sick” vs “Not Sick”

EM physician MUST be the expert in recognition of the TOXIC RASH

Get your consultants involved EARLY

GET NAKED!!!

Thank You!

References

Craig K, Meadows S. What is best duration of steroid therapy for contact dermatitis. Journal of Family Medicine. 2006

Life in the Fast lane

Nguyen T., Freedman J. Emergency Medicine Practice Bulletin. Dermatologic Emergencies: Diagnosing and Managing Life-Threatening Rashes. September 2002.

Tintinalli’s Emergency Medicine. 7th Edition.

Thank you to Helen Mayo, Drs Dustin William, Walter Green