DERMATOLOGICAL EMERGENCIES IN ADULTS.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 Also known as exfoliative dermatitis.   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.  E rythroderma is a potentially life-threatening condition.

5. Aetiology M ultiple 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. 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 . Pruritis occurs in nearly all patients. F ever may be present in more than half of the patients. History taking should include: Known history of inflammatory skin disease? Personal and family history of atopy Detailed drug history Withdrawal of corticosteroids

8. 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.  P atients may have evidence of the underlying causal dermatoses, such as psoriasiform plaques in psoriasis

9. 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.

10. Complications Exfoliative dermatitis 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 to 6 %. Heart failure, septicemia, and pneumonia are the most common cause of death in patients with erythroderma.

11. 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 .

12. Management Erythroderma can be severe and life-threatening and may require admission to the hospital . Management of erythroderma predominantly involves monitoring and ensuring metabolic and hemodynamic stability . E mphasis should focus on symptom management with bed rest and proper wound care, including lukewarm baths, wet dressings, mild topical corticosteroids, and bland emollients . Once identified, the underlying disease process requires attention and appropriate treatment . Findings suggestive of secondary infection warrant antibiotic therapy

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

14. 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

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

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