Those Bumps aren’t Moguls! An Algorithmic Approach to Rashes David Robinson MD Department of...
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Transcript of Those Bumps aren’t Moguls! An Algorithmic Approach to Rashes David Robinson MD Department of...
Those Bumps aren’t Moguls!An Algorithmic Approach to Rashes
David Robinson MDDepartment of Emergency Medicine
University of Texas Medical School at Houston31rst Annual Emergencies in Medicine Conference
Park City, Utah
General ‘Bump’ Terms• Rash: An eruption on the skin; more extensive than a single
lesion• Lesion: Single small, diseased area• Macule: Circumscribed area of change without elevation• Papule: Solid raised lesion ≤1 cm• Plaque: Circumscribed elevated confluence of papules ≥1 cm• Nodule: Solid raised lesion ≥1 cm • Pustule: Circumscribed area containing pus• Vesicle: Circumscribed fluid-filled area ≤1 cm• Bulla: Circumscribed fluid-filled area ≥1 cm• Petechia: Small red/brown macule ≤1 cm that does not blanche
4 Major Rash Algorithms
a. Erythematousb. Vesiculo-bullousc. Petechiae/Purpurad. Maculopapular
Your working at ABEM general when…
• ‘sick baby with red skin in room 5’
• Red Skin, ‘skin is peeling off – when I push on it’, blisters
• Fever
• The 2 key historical points?
Erythema (from the Greek erythros, meaning red) is redness of the skin, caused by hyperemia of the capillaries in the lower layers of the skin
Erythematous Rashes
Erythematous RashSpecial
Finding?Nikolsky sign
Fever?Type of rash?
Erythematous Rash
Yes
YesStaphylococcal SSS
(children)TEN (adults)
NoTSS
Kawasaki disease Scarlet fever
No
Yes TEN
No Anaphylaxis Scombroid Poisoning
Alcohol Flush
Erythematous Rash with feverPositive Nikolsky Sign – the sick ones
• Staph SSS (children <5)– Aka dermatitis exfoliativa
neonatorum– Diffuse scarlatiniform
erythema– No mucous membranes– Shallow skin cleavage
• TEN (adults)– MC associated with sulfa
drugs– First around
face/eyesshoulders and UE– Mortality 30-35%
Erythematous Rash with feverNo Nikolsky sign
• Toxic Shock Syndrome– Diffuse erythematous rash
• Kawasaki Disease– High fever x 5 days– Red eyes, Cracked lips, Dry
tongue
• Scarlet Fever– Pink-red ‘sandpaper’ rash– Flushed face, strawberry
tongue– Follows sore throat or
impetigo
Erythematous RashSpecial
Finding?Nikolsky sign
Fever?Type of rash?
Erythematous Rash
Yes
YesStaphylococcal SSS
(children)TEN (adults)
NoTSS
Kawasaki disease Scarlet fever
No
Yes TEN
No Anaphylaxis Scombroid Poisoning
Alcohol Flush
Erythematous Rash, No Fever and No Nikolsky Sign
• Anaphylaxis– 2 or more body systems
• Scombroid poisoning– Spoiled dark fleshed fish– Intense histamine reaction
30-40 min after ingestion– Flushing, headache, abd
cramps– Self limited, antihistamines
• Alcohol Flush– MC seen in Asians (East)– Self limited
http://dermatology.cdlib.org/126/case_presentations/scrombroid/ferran.html
Erythematous Rash, +/- Fever and (+) Nikolsky Sign
• Toxic Epidermal Necrolysis (TEN)– Associated with drugs– Life threatening shearing
of epidermis from dermis in more than 30% of body
– Affects mucous membranes
– TX: plasmaphoresis, IVIG, stop drug, ICU admit
http://dermatology.cdlib.org/126/case_presentations/scrombroid/ferran.html
A two-fer…
Bed 3• 6 yo with fluid filled vesicles
on face, scalp, torso, upper arms
• Fever• unvaccinated
Bed 9• 60 yo with sharp back and
chest pain• Blisters over specific area of
chest – follows dermatome• No fever
What are the diagnostic clues ? Fever and rash distribution
Vesiculo-Bullous RashDefinitions: Circumscribed fluid filled sac less than 1 cm (vesicle) or greater than 1 cm (bullous)
Vesicles of Hand, foot and mouth
Bullous erythema multiforme
Vesiculo-Bullous RashSpecial
Finding?Distribution
Fever?Type of rash?
Vesiculo-Bullous Rash
Yes
Localized
Necrotizing fasciitisHand, Foot, and Mouth
Diffuse
Varicella/Chicken PoxSmall Pox
Disseminated GCPurpura Fulminans/ DIC
No
Diffuse
Bullous PemphigusPemphigus Vulgaris
Localized
Contact DermatitisZosterBurns
Dyshidrotic Eczema
Vesiculo-Bullous rashFebrile and Localized
• Necrotizing Fasciitis– Rapidly progressing– Polymicrobial, gpA strept
IV ABX
• Hand, Foot and Mouth– Children <10– Coxsackie A16– Vesicles to hands, feet– Symptomatic tx
http://upload.wikimedia.org/wikipedia/commons/6/6a/Necrotizing_fasciitis
Vesiculo-Bullous rashFebrile and Diffuse
• Varicella/ Chicken pox• Smallpox
– Variola v– Born after 1972?
• Disseminated GC– Also seen as palpable purpura
• Purpura Fulminans / DIC– Fever, shock, rapid SQ
hemorrhage, tissue necrosis, DIC– MC meningococcal or G(-)
organisms– Trauma, multiorgan failure
Vesiculo-Bullous RashSpecial
Finding?Distribution
Fever?Type of rash?
Vesiculo-Bullous Rash
Yes
Localized
Necrotizing fasciitisHand, Foot, and Mouth
Diffuse
Varicella/Chicken PoxSmall Pox
Disseminated GCPurpura Fulminans/ DIC
No
Diffuse
Bullous PemphigusPemphigus Vulgaris
Localized
Contact DermatitisZosterBurns
Dyshidrotic Eczema
Vesiculo-Bullous rashNot Febrile and Localized
• Contact Dermatitis– Often linear at point of
irritation
• Zoster– VZV– Follows dermatome pattern
• Burns• Dyshidrotic Eczema
– Pruritic blisters on hands and feet, possibly scaly
– Unknown etiology
• Bullous Pemphigus (~60s)– Neg Nikolsky’s, pruritic– Oral lesions in 1/3
• Pemphigus Vulgaris (>40 y)– Autoimmune blistering of skin
(flaccid bullae) and mucous membranes
– Penicillamine, ACE inh– Treat as burns,
immunosuppressant therapy
Vesiculo-Bullous rashNot Febrile and Diffuse
Hey Doc…I got these Bumps on my skin
• Afebrile • What are the
distinguishing features for these ‘bumps’
• Are they Bumps?– Palpable or
Nonpalpable?
• Do they Blanch?
Petechia: small (< 3 mm) red or purple spot on body due to minor hemorrhage of blood vessel
Purpura: Larger hemorrhagic lesions (3-10mm)
Ecchymosis: largest (>10mm)
Petechial / Purpuric rash
Petechial / Purpuric rashSpecial
Finding?Palpable?
Fever?Type of rash?
Petechial / Purpuric Rash
Yes
Palpable
MeningiococcemiaDisseminatd GC
EndocarditisRMSFHSP
Not palpable
TTPPurpura
Fulminans/DICHSP
No
Not palpable
ITP
Palpable
Vasculitis
Petechial / Purpuric rashFebrile and…
Palpable• Meningococcemia
– Hemorrhagic, petechial with bullae– From endotoxin release
• Disseminated GC• Endocarditis
– Osler’s nodes, roth spots, palpable purpura
• RMSF– Early: Small, flat non-pruritic
macules on wrists forearms and ankles
– Late: spreads to trunk, petechial• HSP
– Kids (2-10)– Vascular palpable purpura– Assoc. GI and joint pain
Petechial / PurpuricFebrile and Not Palpable
• TTP– Microangiopathic hemolytic anemia,
neurologic sx, HUS– Tx with plasma exchange,
immunosuppressants– 2° TTP assoc with ca, platelet agg inh,
immunosuppresants, HIV, SLE
• Purpura Fulminans / DIC– Associated with G- sepsis– Debridement, eschar/amput often
necessary
• HSP (anaphylactoid purpura)– Systemic vasculitis, children– Associated with infection (pharyngitis)– Triad: purpura, arthritis, abd pain
Petechial / Purpuric rashSpecial
Finding?Palpable?
Fever?Type of rash?
Petechial / Purpuric Rash
YesPalpable
MeningiococcemiaDisseminatd GC
EndocarditisRMSFHSP
Not palpable
TTPPurpura
Fulminans/DICHSP
No
Not palpable
ITP
Palpable
Vasculitis
Petechial / Purpuric rashNot Febrile and…
Palpable• Vasculitis
– Vascular damage to capillary sized vessels
Not Palpable• ITP (idiopathic thrombocytopenic
purpura)– Autoimmune in 60%– ½ new cases in children, 70% end in
remission
What are these bumps?Macule: Circumscribed area of change without elevationPapule: Solid raised lesion ≤1 cmNodule: Solid raised lesion ≥1 cmPlaque: Circumscribed elevated confluence of papules ≥1 cmMorbilliform: has both macular and papular features
Pityriasis
Drug eruption
Maculopapular Rash
other finding?
Special Finding?
Distribution?
Fever / ill?Type of rash?
Maculopapular Rash
YesCentral
Viral exanthum Lyme Disease
(erythema migrans)
Peripheral
Target lesions?
Yes: SJS, EM
No: Meningococcemia
RMSF Syphilis Lyme disease
(erythema migrans)
No
CentralDrug reaction
Pityriasis
PeripheralLesion
Distribution?
Flexor:Scabies, Eczema
Extensor:Psoriasis
Maculopapular Rash and Fever
other finding?
Special Finding?
Distribution?
Fever / ill?Type of rash?
Maculopapular Rash
YesCentral
Viral exanthum Lyme Disease
(erythema migrans)
Peripheral
Target lesions?
Yes: SJS, EM
No: Meningococcemia
RMSF Syphilis Lyme disease
(erythema migrans)
No
CentralDrug reaction
Pityriasis
PeripheralLesion
Distribution?
Flexor:Scabies, Eczema
Extensor:Psoriasis
Maculopapular Rashwith Fever and Central distribution
• Viral exanthum– From Gr: ‘breaking out’– Measles, rubella, erythema
infectiosum, roseola…
• Lyme Disease (erythema migrans)– Target lesions (EM) 3-30 d
after bite– Progresses to neuro (10-15%),
cardiac complications
Maculopapular Rashwith Fever and Peripheral Distribution
Target Lesions• Stevens-Johnson Syndrome (SJS)
– Caused from drugs, infections, malignancies
• Erythema multiforme
No Target Lesions• Meningococcemia• RMSF• Syphilis• Lyme Disease
Clinical presentation, history, and presence of toxicity or neurologic deficits will clue the practitioner to the correct diagnosis
Maculopapular Rash and No fever
other finding?
Special Finding?
Distribution?
Fever / ill?Type of rash?
Maculopapular Rash
YesCentral
Viral exanthum Lyme Disease
(erythema migrans)
Peripheral
Target lesions?
Yes: SJS, EM
No: Meningococcemia
RMSF Syphilis Lyme disease
(erythema migrans)
No
CentralDrug reaction
Pityriasis
PeripheralLesion
Distribution?
Flexor:Scabies, Eczema
Extensor:Psoriasis
Maculopapular RashNo Fever and Central Lesions
• Drug Reaction– Fixed or centrally located
• Pityriasis rosea– Assoc. with URI, ha, n,v– Herald’s Patch (2-10 cm
oval red) seen– Last 6 weeks
Maculopapular RashNo Fever and Peripheral Lesions
Lesions on Flexor Surfaces• Scabies
• Eczema
Lesions on Extensor Surfaces• Psoriasis
– Immune mediated, pruritic– Red and white scaly plaques,
patches– 30% with arthritis– Tx with ointments, cr,
phototherapy
Clues to Diagnosis RashPatient Age0 to 5 years: Meningococcemia, Kawasaki disease, viral exanthem>65 years: Pemphigus vulgaris, sepsis, meningococcemia, TEN, SJS, TSS
Rash CharacteristicsDiffuse erythema: Staphylococcal SSS, staphylococcal or streptococcal TSS, necrotizing fasciitisMucosal lesions: EM major, TEN, SJS, pemphigus vulgarisPetechiae/purpura: Meningococcemia, necrotizing fasciitis, vasculitis, DIC, RMSF
SymptomHypotension Meningococcemia, TSS, RMSF, TEN, SJS
Bonus clues to bump identification
Key Summary Points
• Rash with fever is a bad thing• Organize rashes to the 4 major types:– erythematous– macular/papular– petechial/purpura– vesicular-bullous
• Secondary signs (Nikolsky, distribution, location (peripheral vs central, extensor vs flexor)
Now, go hit those bumps
References and Acknowledgments
• Hanson, S, Nigro, J. Pediatric Dermatology. Medical Clinics of North America. 82(6):1381-1403, 1998
• Lampell, MS.Childhood Rashes that Present to the ED. Pediatric EM Practice. EBMedicine.net 4:3,2007
• CDC homepage (www.cdc.gov/meningitis)• Papulosquamous Diseases. dermatitis
emedicine.medscape.com/article/1108312-overview• Murphy-Lavoie, HM. “Approach to Rashes”. Notes from lecture
Oct 27,2008 . ACEP Scientific Assembly• Special thanks to Dr. Ronald Rapini, MD Chair, Dermatology at
University of Texas Medical School at Houston for various photos