DERMATOLOGICAL EMERGENCIES for primary care.pptx

DERMATOLOGICAL EMERGENCIES

1. DERMATOLOGICAL EMERGENCIES HOE HONG MING

2. Case A 40 years old male with “rash” for the past 1o years, came to the clinic saying that he felt feverish for the past 3 days and his rash had “spread across his body”.

3. https://link.springer.com/chapter/10.1007/978-3-662-45139-7_29

4. Erythroderma A clinical finding characterized by diffuse erythema and classically described as involving 90% of the body surface area. It results from a myriad of underlying cutaneous disorders, drugs, and malignancies.  Erythroderma is a potentially life-threatening condition.

5. Aetiology Multiple analyses implicate  psoriasis as the most common causal dermatosis accounting for roughly half of erythroderma cases in certain analyses. Eczema tous dermatoses are also a well-established cause and have also been implicated as the predominant cause of erythroderma in at least one analysis. Other less common dermatoses leading to an erythroderma reaction include pityriasis rubra pilaris, acquired ichthyosis, cutaneous lupus, scabies, bullous pemphigoid, pemphigus foliaceus , actinic dermatoses, and actinic keratosis, among others.

6. Exfoliative dermatitis may also be elicited by certain drugs and heralded by a more typical morbilliform , lichenoid, or urticarial eruption. These drugs include antiepileptics (phenytoin, carbamazepine, and phenobarbital), antibiotics ( sulfonamides , penicillins , and vancomycin), lithium, and allopurinol , among others. 1% of patients with erythroderma have an underlying malignancy. Classically CTCL (cutaneous T-cell lymphoma) such as mycosis fungoides and Sezary syndrome, as well as B-cell chronic lymphocytic leukemia . Cases of solid organ malignancies causing erythroderma has also been reported. Aetiology

7. A clinical presentation for a variety of diseases, often divided into three major categories: (1) primary skin disorders; (2) drug-related; and (3) malignancies, particularly Sézary syndrome and erythrodermic mycosis fungoides. The classification of exfoliative dermatitis into Wilson-Brocq (chronic relapsing), Hebra or pityriasis rubra (progressive), and Savill (self-limited) types may have had historical value, but it currently lacks pathophysiologic or clinical utility.

8. History The classical physical finding of erythroderma is bright red patches that coalesce to cover almost the entire skin surface, followed by the appearance of a white or yellow scale.  The skin may appear glossy and thin, and the patient may complain of tight skin due to progressive lichenification and edema. Pruritus occurs in nearly all patients. Fever may be present in more than half of the patients.

9. Erythroderma may develop acutely over hours or days or evolve gradually over weeks to months. The onset is usually abrupt in drug hypersensitivity reactions. Erythroderma from underlying cutaneous or systemic diseases usually develops more gradually. Depending upon the cause, the erythema may become generalized in hours to days, weeks, or months. Exfoliation typically begins two to six days after the onset of erythema, starts in flexural areas, and rapidly extends to the entire body surface. Scaling is particularly pronounced in patients with underlying psoriasis. Over weeks to months, hair and nail changes may occur. 

10. History taking should include: Age Sex Occupation Duration Peeling of skin Redness Itching Tightness Similar illness in the past – if so , duration & treatment Known history of inflammatory skin disease? Personal and family history of atopy Detailed drug history Withdrawal of corticosteroids

11. By definition, over 90 percent of the skin is involved; the skin is red and warm to the touch. Linear crusted erosions and secondary lichenification may result from rubbing and scratching in chronic erythroderma.  Scaling is a common feature, particularly in erythroderma that has been present for more than a week. Hair ( eg , telogen effluvium, scaling of the scalp) and nail changes (paronychia, nail dystrophy, and onychomadesis [nail shedding]) may be present.  Physical Exam

12. Physical Exam Lymphadenopathy, splenomegaly, and hepatomegaly may be present in almost half of patients and may suggest a drug hypersensitivity or malignancy. Some patients may also present with hair loss and nail findings, including subungual hyperkeratosis, onycholysis , ridging, dry or brittle nails, or nail shedding.  Patients may have evidence of the underlying causal dermatoses, such as psoriasiform plaques in psoriasis

13. Physical Exam  Patients with erythroderma often appear uncomfortable, shiver, and complain of feeling cold. Constitutional symptoms ( eg , malaise, fatigue, fever, or hypothermia) and signs of high-output cardiac failure ( eg , peripheral edema, tachycardia) may also be present. 

14. Investigations Erythroderma is a clinical finding, but correlation with laboratory studies and histopathology is common practice to corroborate clinical suspicion and identify an underlying cause. Lab investigations are usually non-specific . ESR and CRP are elevated in a vast majority of cases. Anemia, leukocytosis, eosinophilia, and abnormal serum protein levels may also be present in some patients. The evaluation of the erythrodermic patient to determine the underlying cause involves a detailed history, physical examination, skin biopsies, and laboratory tests. Specific tests are performed based upon the suspected cause.

15. Complications Erythroderma had previously reported mortality ranging from 4% to 64%, though these numbers are outdated with improved quality of care and management. Several recent case studies have calculated much smaller mortality numbers ranging from 0 to 6%. Heart failure , septicemia , and pneumonia are the most common cause of death in patients with erythroderma.

16. Complications Losing the integrity of this external barrier leads to dehydration and hence oliguric renal failure . Electrolyte imbalance may pursue and complicate the severity of the illness. Protein loss in this situation gives rise to hypoalbuminemia which causes oedema . The fluctuation of temperature, regardless of hypothermia or hyperthermia, may cause dysfunction of the enzymes of the body. The resulting peripheral vasodilatation leads to high-output cardiac failure . Without the skin barrier, the immune system is compromised. The patients are therefore susceptible to systemic infection . It also causes instability of metabolic and endocrine function where the patients are prone to hypercatabolic state and associated with hyperglycaemia .

17. Management Patients with symptomatic erythroderma and patients who are in any way unstable (particularly patients who are hemodynamically unstable) may require hospitalization for initial evaluation and treatment. Regardless of the specific etiology, the initial management involves: Assessment, active management, and ongoing monitoring of the hemodynamic status Replacement of fluid and electrolytes Assessment and management of skin Frequent lubrication of skin with bland emollients such as Vaseline. For more exudative erythroderma, apply wet dressings or clothing. Nutritional support

18. Assessment and management of oral mucosa, eyes, genitourinary tract If eyes appear involved, ophthalmologic assessment is appropriate. If oral involvement precludes eating and drinking, consideration can be given to placement of a nasogastric tube or intravenous fluids. If genitourinary involvement is present, consideration can be given to placement of a urinary catheter. Monitoring of body temperature Patients should be placed in a warm (30 to 32°C) and humid environment to prevent hypothermia. Symptomatic relief of skin pain and itching may include intensive skin care with emollients and wet dressings. Treatment of cutaneous superinfections Symptomatic treatment of skin inflammation and pruritus For the symptomatic treatment of skin inflammation and pruritus, low- to mid-potency topical corticosteroids can be used. Oral antihistamines may be helpful in reducing itching in some patients.

19. https://casereports.bmj.com/content/2018/bcr-2018-225028

20. https://www.researchgate.net/publication/327118405_Clinical_characteristics_culprit_drugs_and_outcome_of_patients_with_Acute_Generalised_Exanthematous_Pustulosis_seen_in_Hospital_Sultanah_Aminah_Johor_Bahru

21. https://pubmed.ncbi.nlm.nih.gov/20713773/

22. References https://www.ncbi.nlm.nih.gov/books/NBK554568/#:~:text=Erythroderma%20is%20a%20clinical%20finding,and%20manage%20this%20condition%20appropriately . https://www.uptodate.com/contents/erythroderma-in-adults https://www.e-mjm.org/2017/v72n2/erythroderma.pdf