R3 Kim Min-joung

Terminology Lesion Rash Primary & Secondary skin lesion General term for a single, small area of skin disease Rash The result of a more extensive process and generally involves many lesions Primary & Secondary skin lesion Primary  secondary Disease evolution or various external factors Ex. Scratching, healing, infection

Macule Papule Nodule Plaque Pustule Vesicle Bulla Petechiae Purpura Scales

Excoriation Lichenification

Cutaneous Drug Reactions Commonly maculopapular rash Most common - sulfonamides, penicillins, anticonvulsants, and NSAIDs 1%-3% of hospitalized patients and 1% of outpatients Most – not serious Life-threatening reactions can occur. Hypersensitivity syndrome, Stevens-Johnson syndrome (SJS), and toxic epidermal necrolysis (TEN).

Cutaneous Drug Reactions Mobilliform Refers to an eruption resembling measles (generalized coexistence of macules and papules) Discrete and confluent

Cutaneous Drug Reactions Can be immunologic or non-immunologic Non-immunologic causes : more than 75% Drug hypersensitivity syndrome Severe, idiosyncratic systemic reaction Often combined with fever, hepatitis, nephritis, carditis, facial swelling, and/or lymphadenopathy. Usually develops 2-6 weeks after a drug is started vs. TEN or SJS : 1-3 weeks Phenytoin, carbamazepine, phenobarbital, sulfonamides, allopurinol, and dapsone

Cutaneous Drug Reactions Treatment Removing the drug Routine use of corticosteroids is not indicated. Antihistamines

Erythema Multiforme Common acute inflammatory disease Usually self-limited Most likely caused by an immune complex-mediated hypersensitivity reaction

Erythema Multiforme Prodrome of malaise, fever, and arthralgia Target lesions - hallmark palms, soles, and extensor surfaces of the extremities, (especially the knees and elbows) usually symmetrical and evolve over 24-48 hours uniform in size (1-2 cm)

Erythema Multiforme In EM minor, mucous membrane involvement is absent. If a single mucous membrane is involved,  EM major Lip, oral cavity, conjunctiva (10%) Generally resolve without treatment in 2-3 weeks.  Essentially all patients diagnosed with EM minor or major can be safely discharged home. Ocular involvement  permanent visual sequelae

Stevens-Johnson Syndrome And Toxic Epidermal Necrolysis Related to the use of certain medication Pathophysiology Altered metabolism and immune-mediated response Prodromal symptoms Myalgia, fever, cough, or sore throat Within days of ingestion. Skin lesions : after 1-2 weeks of prodromal symptoms

SJS and TEN

EM vs. SJS vs. TEN 1) etiology 2) underlying pathology 3) degree of mucosal involvement (mouth, conjunctiva, rectum, vagina, respiratory tract) 4) presence or absence of a “classic rash” 5) degree of epidermal detachment 6) degree of multisystem involvement 7) morbidity and mortality

SJS and TEN Mortality rate Disposition SJS 5%-10% TEN 23%-30% SJS discharge criteria  If not, admission 1) non-toxic, stable vital signs 2) tolerable oral fluids 3) rash is not rapidly progressing. 4) not immunocompromised 5) close follow-up is ensured. TEN : all admission to ICU or burn unit

SJS and TEN Treatment Removal of offending agent All drugs started within the past month should be discontinued. Similar to burn victims Large volumes of colloids and crystalloids Electrolyte balance Steroid (X) No consensus, may increase morbidity and mortality. Aseptic technique Adhesive material, ointments, and creams (X) Cover with clean white Sheet Prophylactic antibiotic therapy (X) Fear of cross-reactivity with the drug that initiated the TEN Risk of selecting for resistant organisms

Pemphigus Vulgaris Autoimmune disease Mean age : the sixth decade Circulating IgG autoantibodies that bind to keratinocytes Loss of cohesion between epidermal cells (acantholysis) Genetic Mean age : the sixth decade Erosions and blistering of epithelial surfaces of the oral mucosa and skin Natural course : progressive over months to years Oral mucosa (weeks~months)  skin of head & trunk  generalized over months

Pemphigus Vulgaris

Pemphigus Vulgaris Treatment Initial treatment : low daily dose of prednisone (1 mg/kg/d) Until remission state of no new blisters for one week If new lesions appear after 1-2 weeks of treatment, the dose of prednisone is increased. Most can be treated at home. not toxic-appearing and only a few blisters Extensive blisters, erosions of the skin, toxic-looking  admission

Meningococcemia Neisseria meningitidis Mortality rate Rash Encapsulated gram-negative diplococcus Mortality rate 10%-20% with prompt treatment 50% : meningitis Rash More than 70% with meningococcemia Wrist and ankles  spread to rest of body

Waterhouse-Friderichsen syndrome Fulminating septicemia Hemorrhagic destruction of adrenal glands

Meningococcemia Treatment : early antibiotics!! Antibiotic prophylaxis Ceftriaxone (2 g q12h) Initial antibiotic of choice to cover the most common bacterial causes of purpuric disease N. meningitidis, H. influenzae, and S. pneumoniae Penicillin G (4 million units q4h) Ampicillin (2 g q6h) Ceftriaxone (2 g q12h) or cefotaxime Chloramphenicol 4 g/d Antibiotic prophylaxis Single dose of ciprofloxacin 500 mg PO Alternative Rifampin 600 mg q12h PO for two days Ceftriaxone 250 mg IM

Rocky Mountain Spotted Fever Rickettsia rickettsii Obligate intracellular coccobacillus April ~ September Mortality : 30% (untreated) Rash Fourth day after the bite Wrist and ankles  spreads centrally to the trunk and proximal extremities CNS, DIC, increased vascular permeability (edema, hypoalbuminemia, hypovolemia), SIADH

Treatment : early antibiotics!! If exposure in endemic area, April~September Fever, headache, rash Serologic test : 2weeks Doxycycline 100 mg BID PO or IV 7days (2days after BT normalize) Pregnancy : chloramphenicol 500 mg QID PO or IV

Henoch-Schönlein Purpura Clinical sx. Cutaneous purpura Arthritis Abdominal pain Gastrointestinal bleeding Nephritis Immunoglobulin A (IgA) Self-limited disease of approximately one month’s duration Corticosteroids

Toxic Shock Syndrome Staphylococcal Toxic Shock Syndrome (TSS) Streptococcal Toxic Shock Syndrome (STSS) TSS 55% : tampon-mediated 45% : abscesses, bursitis, surgical wounds, indwelling foreign bodies such as nasal packing, and in post-partum patients STSS Soft-tissue infection or minor skin trauma

Toxic Shock Syndrome TSS STSS Diffuse macular erythroderma  desquamation STSS Pain at site of infection 55% necrotizing fasciitis

Toxic Shock Syndrome Mortality Treatment TSS : 2%-5% STSS : 30%, 80% in elderly Treatment Aggressive resuscitation Antibiotics Steroid : controversial All patients should be admitted.

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Ten Pitfalls To Avoid

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