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(+)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

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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

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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

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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

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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

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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

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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

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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

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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, 2008. 2. Ashton, R. and B. Leppard. Differential Diagnosis in Dermatology.

3rd Ed. Radcliffe Publishing, United Kingdom 2005.

3. Baroni, A., et al. Vesicular and Bullous disorders: Pemphigus. Dermatol Clin 25 (2007) 597 – 603.

4. Bassam Z, et al. Pemphigus Vulgaris. on web at http://www.emedicine.com/DERM/topic319.htm

5. Braunwald, et. al. Harrison¹s Principles of Internal Medicine. 15th Ed. McGraw Hill, New York, 2001.

6. Buckingham SC, et al. Clinical and Laboratory Features, Hospital Course, and Outcome of Rocky Mountain Spotted Fever in Children. J Pediatrics 2007; 150: 180-4.

7. Carr, D., Houshmand, E., and M. Heffernan. Approach to the Acute, Generalized, Blistering Patient. Semin Cutan Med Surg 26: 139 – 146, 2007.

8. Chan, L. Bullous Pemphigoid. Emedicine (2008). http://emedicine.medscape.com/article/1062391.

9. Chapman AS, et al. Rocky Mountain Spotted Fever in the United States, 1997-2002. Ann. N.Y. Acad. Sci. 2006; 1078: 154-155.

10.Chia, F., and K.P. Leong. Severe Cutaneous Adverse Reactions to Drugs. Curr Opin Allergy Clin Immunol 7: 304 – 309, 2007.

11.Fleischer, A., et. al. Emergency Dermatology: A Rapid Guide to Treatment. McGraw Hill, New York, 2002.

12.Ghatan, H. Dermatologic Differential Diagnosis and Pearls. 2nd Ed. Parthenon Publishing, New York, 2002.

13.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 1 – 15.

14.Harwood-Nuss, A., et. al. The Clinical Practice of Emergency Medicine. 2nd Ed. Lippincott-Raven, Philadelphia, 1996.

15.Hom, C. Vasculitis and Thrombophlebitis. Emedicine (2008). http://emedicine.medscape.com/article/1008239.

16.Mukasa, Y., and N. Craven. Management of Toxic Epidermal Necrolysis and Related Syndromes. Postgrad. Med. J. 2008: 84: 60 – 65.

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17.Nguyen, T and J Freedman. Dermatologic Emergencies: Diagnosing and Managing Life-Threatening Rashes. Emergency Medicine Practice, Volume 4 (9) September 2002. 18.Sauer, G., and J. Hall. Manual of Skin Diseases. 7th Ed. Lippincott-Raven, Philadelphia,

1996.

19.Slaven, EM, et al. Infectious Diseases: Emergency Department Diagnosis and Management. McGraw Hill, New York, 2007.

20.Tintinalli JE, et al. Emergency Medicine: A Comprehensive Study Guide. 6th Edition. McGraw Hill, New York, 2004.

21.Wolf, R., et al. Drug Rash with Eosinophilia and Systemic Symptoms vs. Toxic

Epidermal Necrolysis: the Dilemma of Classification. Clin Derm (2005) 23, 311 – 314. 22.Margileth, A. Scaled Skin Syndrome: Diagnosis, Differential Diagnosis, and

Management of 42 Children. South Med J. (1975) 68: 447 - 54. 23.Yamamoto, L. Kawasaki Disease. Ped Em Care. (2003) 422 – 427.

24.Levi, M. Disseminated Intravascular Coagulation. Crit Care Med. (2007) 35: 2191 – 2195.

25.Levi, M. Novel Approaches to the Management of Disseminated Intravascular Coagulation. Crit Care Med. (2000) 28: S20 – S24.

26.Sarode, R. Atypical Presentations of Thrombotic Thrombocytopenic Purpura: A Review. 

J Clin Apheresis. (2009) 00: 000 ‐ 000.  27.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: 149 –153.  28.Mittimann, N, et al. IVIG for the Treatment of Toxic Epidermal Necrolysis.  Skin  Therapy Lett. 2007 Feb;12(1):7‐9.                                           

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UNKNOWN RASH SELF-ASSESMENT 1. _______________________________________ 2. _______________________________________ 3. _______________________________________ 4. _______________________________________ 5. _______________________________________ 6. _______________________________________ 7. _______________________________________ 8. _______________________________________ 9. _______________________________________ 10._______________________________________

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