(+)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, 2009 9:00 AM - 9:50 AM
Boston Convention & Exhibition Center
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.
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
III.
Physical Exam
a.
Vital signs
i.
Hypotension
ii.
Tachycardia
iii.
Fever
iv.
Mental Status Change
b.
Distribution
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
ALGORITHM ERYTHEMATOUS RASH
Differential Diagnosis:
Staph SSS = Staphylococcal Scaled Skin Syndrome - children, IV Penicillinase-resistant 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 self-limited
Alcohol flushing - history of alcohol ingestion, prior episodes, no itching, normal vitals, no fever, self-limited
ERYTHEMATOUS RASH FEBRILE AFEBRILE NIKOLSKY’S SIGN YES NO Staph SSS (child) TEN (adult)
Toxic Shock (mucous membranes)
Kawasaki Syndrome (child, hands)
Scarlet Fever (sand paper)
FEBRILE AFEBRILE
TEN (adult)
Anaphylaxis Scombroid Alcohol Flush
ALGORITHM MACULOPAPULAR RASH
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 MACULOPAPULAR RASH YES NO CENTRAL DISTRIBUTION PERIPHERAL DISTRIBUTION Viral Exanthem Lyme Disease (erythema migrans) TARGET LESIONS Drug Reaction Pityriasis (herald patch)
FEVER / ILL? FEVER / ILL?
YES NO YES NO Stevens-Johnson TEN Erythema Multiforme Meningococcemia Rocky Mountain Spotted Fever Syphilis Lyme Disease (erythema migrans) Scabies Eczema LESION DISTRIBUTION FLEXO EXTENSOR Psoriasis
ALGORITHM VESICULO-BULLOUS RASH
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
VESICULO-BULLOUS RASH
DIFFUSE DISTRIBUTION
FEBRILE AFEBRILE
Varicella / Chicken Pox Small Pox Disseminated GC Purpurpa Fulminans / DIC
Necrotizing Fasciitis Hand Foot Mouth
LOCALIZED DISTRIBUTION DIFFUSE DISTRIBUTION Bullous Pemphigus Pemphigus Vulgaris Contact Dermatitis Herpes Zoster Dyshidrotic Eczema Burns LOCALIZED DISTRIBUTION
ALGORITHM PETECHIAL/PURPURIC RASH
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/mm3 – 10000/mm3, emergent Hematology consultation
PETECHIAL / PURPURIC RASH
PALPABLE
FEBRILE & TOXIC AFEBRILE & NON-TOXIC
Meningococcemia Disseminated GC
Endocarditis RMSF
HSP
Purpurpa Fulminans / DIC TTP
NOT PALPABLE PALPABLE Cutaneous
Vasculitis
ITP NOT PALPABLE
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 THE VERY OLD
Staph SSS, Kawasaki’s disease, viral exanthem, meningococcemia
pemphigus vulgaris, sepsis, TEN, SJS
TOXIC IMMUNOSUPPRESSED
necrotizing fasciitis, meningococcemia, TEN, SJS, TSS, RMSF, TTP
necrotizing fasciitis, meningococcemia, endocarditis, herpes zoster, sepsis
DIFFUSE ERYTHEMA PETECHIAE / PURPURA
staph SSS, staph TSS, strep TSS, TEN
meningococcemia, endocarditis, TTP, ITP vasculitis, DIC, RMSF
MUCOSAL LESIONS HYPOTENSION
EM major, TEN, SJS, pemphigus vulgaris
meningococcemia, TTP, 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
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
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UNKNOWN RASH SELF-ASSESMENT 1. _______________________________________ 2. _______________________________________ 3. _______________________________________ 4. _______________________________________ 5. _______________________________________ 6. _______________________________________ 7. _______________________________________ 8. _______________________________________ 9. _______________________________________ 10._______________________________________