Dermatologic disorders commonly missed in the ED.pptx

Dermatology lecture

1. Dermatologic Disorders Commonly missed in the ED. Donny Perez, DO and Michael Tomlinson RN

2. Defi n itio ns Macule Impalpable colored lesion <1cm, circumscribed alteration of skin color Patch Impalpable colored lesion >1cm.

3. Papule Palpable lump <1cm diameter. Nodule Palpable lump >1cm.

4. Vesicle Palpable fluid filled lesion <1cm. Bulla Palpable fluid-filled lesion >1cm

5. Petechiae red, non blanching spots <5mm Purpura red, non blanching spots >5mm

6. Pla q ue = Palpable disc shaped lesion Wheal = Area of dermal edema

7. Descriptive Terms Annular : Ring shaped, hollow centre Arcuate : Curved Circinate : Circular Confluent : Lesions that run together Discoid : Circular without hollow centre Eczematous : Inflammed and crusted Keratotic: Thickened Lichenified: Thickened and roughed with accentuated skin markings Zosteriform : Nerve distribution

8. Histo ry How long Had it before Is it worsening / anything improving it Distribution ie palms / plantar / face / mucosal membranes How did it start / evolve Itch Social changes eg diet / work / cleaning Meds & allergies Cutaneous manifestations of systemic disorders eg sore joints & past medical history Family history Travel Contacts Viral symptoms or fevers

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10. Urtic a ria

11. Urtic a ria Physical triggers / drugs / foods / stings / viral/ atopy / blood products / temperature... Wheals, smooth with a red flare with some clearing leaving annular pattern & scratch marks. Dermatographism Acute / Recurrent / Chronic Management Remove cause / anti-histamines / steroids

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13. Eczema Flexural Distribution Itch ++ / Scratch marks, hyper or hypopigmented lesions Age related stages Atopic vs Contact Can be vesicular Treatment Emollients ++ Treat infected skin Moist dressings Avoid triggers Antihistamines for itch Topical / systemic steroids Increase sunlight exposure / Phototherapy Immunomodulators / Immunosupressants : Cyclosporin / Azathioprine / Tacrolimus /

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15. Psori a sis Itch / Pain / Decreased movement / F amily Hx Extensor Distribution – well demarcated salmon pink silvery scales. Red surface on removal / capillary bleeding (Auspitz sign)/ new lesions at site of trauma (Koebner’s Phenomenon) Plaque / Guttate / Erythrodermic / Pustular variants / Inverse Triggers – Stress, Strep, HIV, Trauma, Drugs (Lithium + BetaBlockers Especially) Psoriatic Arthritis Treatment – topical vs systemic : Systemic if failed topical / repeated admissions / extensive plaques in elderly / severe arthropathy / generalised pustular or erythrodermic psoriasis Emollients ++ / Keratolytic agents Topical Steroids. Coal Tar. Dithranol. Vitamin D3 Retinoids – topical or oral. Phototherapy / Photochemotherapy (& methotrexate) Immunosuppressant's – Methotrexate, Cyclosporin, Mycophenalate Infliximab / CD4 monoclonal antibodies

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18. V aricella zoster Virus Varicella / Chicken Pox – Respiratory droplets. Infectious for 2 days prior to lesions. Ends when crusts Rash head / trunk / Simultaneous presence of rash at different stages. Macule / Papule / Vesicle / Pustule / Crusts A/w headache / malaise / anorexia / cough / coryza and sore throat / low grade fever Rx symptomatic. Antivirals in certain cases / Secondary infection risk Shin gles Dermatomal distribution & enlarged draining node Presents as pain, malaise, fever, rash in same distribution several days later Dx Clinical but can do smears or titres or isolation of virus in blisters Mx – antivirals / pain relief / IV antivirals if immunocompromised Complications : Corneal ulcers / Gangrene of affected area / Phrenic Nerve palsy / Meningoencephalitis / Ramsay Hunt syndrome / Neuralgia / Disseminated zoster

19. Nursing considerations Place patient on airborne and contact precautions Anticipate antivirals Non adherent dressings Pain management Educate patients on self care - Calamine lotion and cold compresses - Keep rash dry and avoid lotion/creams

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22. H erpes Simplex Virus Pain / Itch / Vesicles / Sore mouth / Gum swelling / Mouth ulcers Small vesicles & lymph nodes Complications – Erythema Multiforme / Encephalitis / Keratitis / Whitlow / Disseminated infection if immunocompromised / Visceral involvement / Neonatal / Meningitis Rx topical / oral / IV antivirals

23. Nursing Considerations Distinguish HSV type 1 and HSV type 2 Administer antiviral therapy Pain management Educate patient to avoid sexual contact during outbreak Emphasize importance of protected sex Encourage patients that condition is manageable Trigger factors for outbreak -Stress -illness

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25. Impeti g o Group A beta haemolytic Strep or Staph aureus Contagious Vesicles to honey coloured crusted lesions. Painless. Face or extremities Local adenopathy / Generally afebrile Rx topical / oral antiobiotics Generally resolves 7-10 days Complications – Osteomyelitis / Septic Arthritis / Sepsis / Pneumonia / Endocarditis Post strep glomerulonephritis / Scalded skin syndrome

26. Nursing considerations Contagious with present lesions (Contact Precautions) Assess for fevers and possible systemic infection Determine exposure Encourage hand washing Administer antibiotics

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28. Erythema Multiforme Hypersensitivity reaction, polymorphous skin eruption Tar g et Lesions Symmetric eruption red round macules, edematous papules, target lesions (x3 concentric areas of colour change) dorsum hands and forearms Central dusky area Can be vesicular and painful. Minor generally self limiting Etiology HSV Immunologic disorders – IBD / SLE / graft vs host Mycoplasma, TB, Histoplasmosis. Drugs: Sulphonamides. Barbiturates. Penicillin. Phenytoin. NSAIDS. Allopurinol. Malignancy Idiopathic Mx – Minor consider antivirals if HSV / symptomatic

29. Nursing management Determine risk factors Educate patient to keep diary of outbreaks Avoid triggers Treat underlying conditions

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31. Erythema Nodosum Painful nodules, poorly defined. +++ tender Hx – fever / painful nodules/ arthralgias / sore throat / drugs / Cough E tiology: Strep / TB / Yersinia / Leprosy / Coccidioidomycosis / Histoplasmosis Sarcoid SLE Behcets IBD Drugs – Sulphonamides / OCP Management Definitive dx – wedge biopsy CXR Rapid strep / Throat Swabs. Symptomatic Self–limiting - 3-6 weeks NSAIDS Elevation Compression Stockings.

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33. Koplik’s Spots / Measles Primary infection respiratory epithelium - droplets Highly contagious Fever / Coryza / Koplik spots 2-3 days into prodrome precedes rash (14 days). Maculopapular, lasts 5-7 days, may desquamate Clinical diagnosis of Measles wrong in 50% of cases Probably requires serology for confirmation / leu k openia / lymphopenia Complications: Superimposed bacterial infection. Encephalitis

34. Nursing considerations Communicable period- 4 days before rash appears and ending 4 days after rash has been present Determine risk factors such as outbreaks, travel and immunization Airborne precautions Advise patients to avoid contact during communicable period

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36. Slapped Cheek Syndrome Fifth Disease “Erythema infectiosum” Parvovirus B19 Respiratory droplets Viral prodrome, slapped cheek, perioral pallor, later extremities with palms and soles spared . Antipyretics and antihistamines Generally benign. Rare aplastic crisis. In utero a/w hydrops foetalis

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38. Hand, Foot + Mouth Usually Coxsackie A or Enterovirus Usually children, very infectious, incubation 3 days then fever malaise and rash / painful oral lesions Treatment supportive

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40. Pityriasis Rosea Presumed viral. ?HHV 7. Christmas tree distribution. Self limiting over 6-12 weeks. Herald patch often mistaken for ringworm.

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42. Scabi es Sarcoptes scabiei Intense itch Permethrin or Malathion Applied at bedtime to whole body from scalp to soles. Treat all close contacts even if asymptomatic. Wash all towels, clothes worn in last week and bed linen Vacuum house and furniture! Itch can persist for 6 weeks even after successful treatment due to dead mites in skin.

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44. Me l an o ma Asymmetrical Border irregular Varicolored Diameter >5mm Elevation

45. Decubitus ulcers Results from prolong pressure to bony area of the skin including (sacrum, heels, shoulder, hip, ankles)

46. Nursing Management Determine patients at risk Assess for signs of infection Wound culture if indicated Document wounds and take pictures Cover open wounds with non adhesive dressings Keep patients dry Reposition patients frequently and pad bony prominences Wound care consult

47. So far... Reviewed terminology Common, but usually not serious/life threatening conditions

48. Serious conditions with blistering / skin loss Erythema Multiforme major / SJS Pemphigus Pemphigoid TENS SSS ( Kawasaki’s )

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50. Erythema Multiforme Major Stevens Johnson Syndrome Symmetric erythematous macules, head and neck and lower body Progresses to bullae, skin necrosis and denudation, at least 2 mucosal surfaces involved Widespread rash involving up to 10% BSA skin sloughing / blistering. Treatment: Prompt drug withdrawal. Admission / supportive care / general burns care.

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52. Toxic Epidermal Necrolysis Widespread rash like sunburn initially >30% TBSA with later necrosis and sloughing. +ve Nikolsky sign Large mucous membrane involvement. Remove causative agent & manage as severe burns (ICU / Burns unit) Mostly thought to be drug related Debates re : plasmapheresis / I VI G / Steroids etc, nil proven Complications : High mortality Ophthalmology involvement and regular eye irrigation

53. Nursing management of SJS/TEN Obtain thorough background information Cover open wounds to prevent infection Pain management and fluid replacement Educate patient on risk factors Anticipate transfer to burn unit

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55. Pemp h ig us Autoimmune Blisters in mouth followed by on skin. Positive Nikolsky Sign 3 Types: Vulgaris – begins in mouth 50% cases Foliaceous – may be drug induced Least severe. Often mistaken for eczema Paraneoplastic. N on H odgkins L ymphoma most common T x : A ntib iotics / IV fluids / systemic steroids +/- immunosuppressants (azathioprine / cyclophosphamide / methotrexate / gold / dapsone / c y closporin e )

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57. Pemp h ig o id More common than pemphigus Generally benign Also Autoimmune Affects older age group No Mucous Membrane involvement Negative Nikolsky Sign Treatment same as Pemphigus – steroids +/- immunosupressants Variants Gestational Mucous membrane (Cicatricial)

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59. Scalded Skin Syndrome Syndrome of acute exfoliation of the skin typically following an erythematous cellulitis. Severity varies from a few blisters to a severe exfoliation affecting almost the entire body, but doesn’t involve mucous membranes as in TENS . Staph aureus with epidermolytic exotoxins (A+B). Positive Nikolsky’s sign - separation of skin with gentle pressure. Treatment. Antibiotics, supportive care.

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61. Purpuric Rash Petechiae <5mm. Purpura >5mm. Causes: Drugs : Steroids / Gold / Anticoagulants Senile Trauma Coughing / vomiting Infection Meningococcal, Cellulitis, Viral. Vasculitic E.g. HSP / Wegners Thrombocytopenia ITP / TTP / Leukemia / DIC.

62. Other Serious skin conditions Necrotizing fasciitis Rocky mountain spotted fever Hereditary Angioedema

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66. Red flags Unwell patient Other serious comorbidity, eg immunodeficiency Large area of skin Mucosal or ocular involvement Specific conditions with serious complications