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Flashcards in Acute and emergency dermatology Deck (56)
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1

What % of body mass of an average person is made up of skin?

10%

2

List some normal functions of skin

– Mechanical barrier to infection
– Temperature regulation
– Fluid and electrolyte balance
– Vitamin D synthesis
– Sensation

3

List some consequences of skin failure

Sepsis
Hypo- and Hyper- thermia
Protein and fluid loss
Renal impairment
Peripheral vasodilation: can lead to cardiac failure

4

Define erythroderma

A descriptive term rather than a diagnosis
“Any inflammatory skin disease affecting >90% of total skin surface”

5

What can cause erythroderma?

– Psoriasis
– Eczema
– Drugs
– Cutaneous Lymphoma
– Hereditary disorders

6

How do you manage erythroderma?

• Appropriate setting - ?ITU or burns unit
• Remove any offending drugs
• Careful fluid balance
• Good nutrition
• Temperature regulation
• Emollients – 50:50 Liquid Paraffin:White Soft Paraffin
• Oral and eye care
• Anticipate and treat infection
• Manage itch
• Disease specific therapy; treat underlying cause

7

What % of inpatients have drug reactions?

2-3%

8

When do drug reactions usually present on first exposure and second exposure?

Commonly 1-2 weeks after drug

Within 72 hours if re-challenged

9

What is an example of a mild drug reaction?

Morbilliform exanthem (rash that looks like measles)

10

Give some examples of dermatological presentations seen following severe drug reactions

Erythroderma
Stevens Johnson Syndrome/Toxic epidermal necrolysis
DRESS

11

What are some causative drugs to Stevens Johnson Syndrome (SJS) and Toxic Epidermal necrolysis (TEN) reactions?

– Antibiotics
– Anticonvulsants
– Allopurinol
– NSAIDs

12

How can SJS be differentiated from toxic epidermal necrolysis?

Prodrome - SJS more like flu, TEN more like fever

TBSA affected - SJS <10%, TEN >30%

Age - SJS more common in kids, TEN in adults

Onset time - SJS slower, TEN very rapid

13

Describe the clinical features of SJS

URI like prodrome: Fever, malaise, arthralgia

Rash
– Maculopapular, target lesions, blisters
– Erosions covering <10% of skin surface

Mouth ulceration
– Greyish white membrane
– Haemorrhagic crusting

Ulceration of other mucous membranes

14

Describe the clinical features of toxic epidermal necrolysis

Often presents with prodromal febrile illness (fever)

Ulceration of mucous membranes

Rash
– May start as macular, purpuric or blistering
– Rapidly becomes confluent
– Sloughing off of large areas of epidermis – ‘desquamation’ > 30% BSA
– Nikolsky’s sign may be positive

15

Describe a positive Nikolskys sign

when slight rubbing of the skin results in exfoliation of the outermost layer.

16

How do you manage Stevens Johnson syndrome and Toxic epidermal necrolysis?

• Identify and stop culprit drug as soon as possible
• Supportive therapy
• ?High dose steroids
• ?IV immunoglobulins
• ?Anti-TNF therapy
• ?Ciclosporin

17

Compare the mortality of SJS to toxic epidermal necrolysis

10% (SJS)
30% (TEN)

18

What is SCORTEN?

SCORTEN - a severity-of-illness scale with which the severity of certain bullous conditions can be systematically determined. It was originally developed for toxic epidermal necrolysis, but can be used with burn victims, sufferers of Stevens-Johnson Syndrome, cutaneous drug reactions, or exfoliative wounds.

19

What is the mortality risk associated with a SCORTEN score of 0-1?

>3.2%

20

What is the mortality risk associated with a SCORTEN score of 2?

>12.2%

21

What is the mortality risk associated with a SCORTEN score of 3?

35.3%

22

What is the mortality risk associated with a SCORTEN score of 4?

>58.3%

23

What is the mortality risk associated with a SCORTEN score of 5 or more?

>90%

24

What are some long term complications seen in those who have had SJS or toxic epidermal necrolysis?

o Pigmentary skin changes
o Scarring
o Eye disease and blindness
o Nail and hair loss
o Joint contactures

25

Describe erythema multiforme

Hypersensitivity reaction usually triggered by infection
Most commonly HSV, then Mycoplasma pneumonia
Abrupt onset of up to 100s of lesions over 24 hours
– Distal => proximal
– Palms and soles
– Mucosal surfaces (EM major)
– Evolve over 72 hours
Pink macules, become elevated and may blister in centre
• “Target” lesions
• Self limiting and resolves over 2 weeks
• Symptomatic and treat underlying cause

26

How do you treat erythema multiform?

Self limiting and resolves over 2 weeks
Symptomatic and treat underlying cause (infection)

27

What does DRESS stand for?

Drug Reaction with Eosinophilia and Systemic Symptoms

28

Describe Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS)

• Onset 2-8 weeks after drug exposure
• Fever and widespread rash
• Eosinophilia and deranged liver function
• Lymphadenopathy
• +/- other organ involvement

29

When does DRESS occur following drug exposure?

2-8 weeks after drug exposure

30

How is DRESS treated?

Stop causative drug
Symptomatic and supportive treatment
• Systemic steroids
• +/- Immunosuppression or immunoglobulins