1. R3 Kim Min-joung

2. 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

3. Macule
Papule
Nodule
Plaque
Pustule
Vesicle
Bulla
Petechiae
Purpura
Scales

4. Excoriation
Lichenification

8. 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).

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

10. 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

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

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

13. 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 hours
uniform in size (1-2 cm)

14. 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

16. 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

17. SJS and TEN

18. 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

19. 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

20. 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

21. 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

22. Pemphigus Vulgaris

23. 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

26. 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

27. Waterhouse-Friderichsen syndrome
Fulminating septicemia
Hemorrhagic destruction of adrenal glands

28. 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

29. 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

30. 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

31. 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

33. 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

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

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

37. Ten Pitfalls To Avoid

38. Ten Pitfalls To Avoid

39. Ten Pitfalls To Avoid

40. Ten Pitfalls To Avoid

41. Ten Pitfalls To Avoid

42. Ten Pitfalls To Avoid

43. Ten Pitfalls To Avoid

44. Ten Pitfalls To Avoid

45. Ten Pitfalls To Avoid

46. Ten Pitfalls To Avoid