DERMATOLOGY

Alison Ruiz PA-C

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Molluscum Contagiosum • Pox virus • Spreads by direct skin

contact – Especially in kids – In adults usually spread

with sexual contact. • Well circumscribed, small

erythemaotus paupules with a small central indentation – Central indentation

resolves as lesions progress

• No treatment required in healthy individuals

• Can use Imiquimod cream 5% (same as used for HPV in the genital skin

• In children, freezing, curettage, topical cantharidin

Erythema Infectiosum • Fifth’s disease • Occurs in spring in children

– 5-15 yrs of age usually • Human parvovirus B19 • Abrupt onset of fiery red

rash on cheeks – Slapped cheek appearance – Closely grouped tiny papules

on erythematous base • 1-2 days later

– erythematous maculopapular rash on trunk and limbs

• Fevers, malaise, headache, Sorethroat, cough, coryza, nausea, vomiting, diarrhea and myalgia

Case Presentation

• 25 y/o M PMH Seizure Disorder recently diagnosed presents to the ED with fevers for the 4 days and URI symptoms.

• He noticed a rash for the past 72 hours to his chest and back. Rash initially itchy but now it it more painful, warm and “cracking”

• Pt feels weak, has not been eating. Fever max 103.5. States he was placed on Keppra after recent diagnosis of seizure disorder.

History

• PMH – Seizures

• PSH – None

• Meds – Keppra

• Allergies – none

• FH – Noncontributory

• SH: – smoker 5 cigaretteres

per day for 5 years – Alcohol 4 drinks per

week

Physical Exam • HEENT: PERRL, EOMi • Neck supple. No nuccal

rigidity • Lungs: CTA bilat. No

W/R/R • CV RRR s1s2 • Abd: soft NT ND NABS. • Skin: see picture • Back: see picture • Ext: small maculopapular

lesions on thighs and lower legs bilat.

Differential Diagnosis

• ??????

What labs do you want to send?

• CBC • BMG • LACTIC ACID • BLOOD CULTURES • URINALYSIS • URINE CULTURE • CXR

LAB RESULTS

• CBC – WBC: 20.4 (H) – RBC: 3.33 (L) – HEMOGLOBIN: 11.4 (L) – HCT: 28.6 (L) – MCV: 85.7 – MCH: 28.2 – MCHC: 32.9 – RDW: 16.5 (H) – PLATELET COUNT: 199

• BMG – GLUCOSE: 102 (H) – SODIUM: 140 – POTASSIUM: 3.5 – CHLORIDE: 109 (H) – CO2: 26 – BUN: 22 – CREATININE: 1.1 – CALCIUM: 8.2 (L)

LAB RESULTS

• Lactic Acid – LACTIC ACID: 3.6

• CXR – WNL

• BLOOD CULTURES PENDING

URINALYSIS • COLOR: YELLOW • APPEARANCE: CLEAR • SPECIFIC GRAVITY: 1.019 • PH: 6.0 • PROTEIN: NEGATIVE • GLUCOSE: NEGATIVE • BILIRUBIN, URINE: NEGATIVE • NITRITE: NEGATIVE • KETONES: NEGATIVE • BLOOD: NEGATIVE • UROBILINOGEN: 1.0 • LEUKOCYTE ESTERASE: NEGATIVE • SQUAMOUS EPI: 3 • HYALINE CASTS: 0 • BACTERIA: NEGATIVE • WBC, URINE: 1 • RBC: 2

48 hours later….

What is the most likely Diagnosis?

Erythema Multiforme

• ACUTE INFLAMMATORY DISEASE

• Range – Papular eruption of the

skin (EM minor) to severe multisystem illness (EM major) with

• Vesiculobullous lesions and erosions of the mucous membranes known as Stevens-Johnson syndrome

• Characterized by epidermal detachment

Epidermal Detachment EM Minor • No epidermal detachment

Stevens-Johnson Syndrome • <10% epidermal

detachment

Overlapping SJS and TEN • 10-30% epidermal

detachment

TEN • >30% epidermal

detachment

The more epidermal detachment, the higher

risk of death

Erythema Multiforme

• Affects all ages – Incidence highest 20-40

yrs

• 2:1 Males:Females • Occurs in fall and spring • Symptoms

– Malaise, fevers, myalgias, arthalgias

– Pruritus or burning from skin lesions

• Precipitating Factors – Infections

• Mycoplasma • HSV

– Drugs • Antibiotics • Anticonvulsants

– Malignancies – Unknown cause in 50%

of cases

Erythema Multiforme Lesions

Maculopapular lesions Target or Iris lesion

Management

• Hospitalize • Steroids used for localized disease and prove

sympotmatic relief • Systemic analgesics and antihistamines for

symptom relief • Ocular involvement requires optho consult

Toxic Epidermal Necrolysis

• Explosive dermatosis – Tender erythema, bullae

formation and exfoliation.

• Found in all age groups • Males=Females • Medications are most

common cause – Sulfa, PCN,

anticonvulsants, oxicam, NSAIDS

TEN

• 25%-35% mortality • Presentation

– 1-2 wk prodrome of malaise, arthalgias, fevers, anorexia

– Skin tenderness, erythema which starts with the eyes, nose, mouth and genitalia

– Nikolsky sign • Management

– Hospitalization in ICU, optimally a burn unit

Nikolsky Sign

• Slippage of the th epidermis from the dermis when slight tangential or rubbing pressure is applied to the skin.

• Seen in bullous disorders, TEN and staphlyoccocal scalded skin syndrome

Differential Diagnosis

Pemphigus

Pemphigoid

Erythema Multiforme

Exfoliative erythemoderma

Toxic Shock Syndrome

Scalded Skin Syndrome

Kawasaki’s disease in children

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Erythema Nodosum

Inflammatory eruption of the SQ fat.

• Fungal, bacterial, parasitic, viral, pharmacologic, sarcoidosis, inflammatory bowel disease, pregnancy, behcet syndrome, leukemia and lymphoma, idiopathic

Causes

• Tender, warm, ill-defined erythematous nodules

Clinical features

• Bed rest, leg elevation, NSAIDS • Treat underlying cause

Treatment

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Urticaria • Wheal • Why do we get them?

– Allergic – Idiopathic

• ID swelling in respiratory tract – Look for lip, mouth throat

swelling and listen to lungs • Treatment

– Steroids – Benadryl

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Pemphigus Vulgaris • Autoimmune

– Autoantibodies against part of the epidermal layer

• Primary lesions – bullae or vesicles

• Affects head, trunk, mucous membranes first

• Then blisters rupture & become painful and denuded

• Decreased fluid intake, accelerated protein, fluid and electrolyte loss through the involved skin – Leads to hypovolemia and

electrolyte disturbances • Admit • Aggressive fluid and

electrolyte administration • Steroids and

immunosuppressives to prevent death

• +/- plasmapheresis and IV immunglobulin

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• Diffuse infection • Caused by toxins produced by serotypes A and

B from Staph – Causes the exfoliative presentation

• Fevers, malaise, irritability and tenderness over the skin

• Most are <2 yrs old and almost all are <6 yrs old

Staphylcoccal Scalded Skin Syndrome (SSSS)

Treatment of SSSS

• Diffuse Disease – Admit

• Use burn unit if disease is extensive

– IV fluids – IV antibiotics

• Localized Disease – Outpt therapy with f/u

• Nafcillin IV • Pencillin G IV • AugmentinPO • Cefazolin IV • Cephalexin PO • If suspect MRSA, then

include Clindamycin, bactrim or Vancomycin

Case Presentation

• 7 y/o M c/o with rash and ST. Pt has had ST for 3 days. Developed fevers 2 days ago. Fever max 102.1. Pt vomited once. Drinking less because of throat pain. Rash started today. Mom unable to see the pediatrician.

• Using motrin for fevers • Kids at school are sick but mom is not sure

with what.

History

• PMH: none • Peds Vacc UTD • PSH: none • Meds: Motrin • Allergies: NKDA

Physical Exam • Vitals; 100.5 po, R: 20, HR 90, BP 101/50, Pulse ox 100% • Alert and oriented times 3 NAD. Pt is quiet but looks well

hydrated. • HEENT: PERRL EOMi • TMs clear bilat without bulging or erythema • OP: erythema, exudate. Enlarged tonsils. Uvula midline.

No petechiae • Neck: anterior cervical LAD • Lungs; CTA bilat. No W/R/R • CV RRR s1s2 • Abd: soft NT ND NABS. No HSM • Skin: see picture

Oropharynx

Presenter

Presentation Notes

Scarlet fever rash

What to do next?

• What labs/imaging do you want?

Differential diagnosis

• Strep throat • Scarlet fever • Viral exanthems • Pharyngeal abscess

Diagnosis:

• Rapid strep: positive • STREP + RASH=?????

Scarlet Fever • Affects children • Group A B-hemolytic

strep • Fever, ST, HAs, vomiting,

abd pain • Exanthem 1-2 days later

– Sandpaper rash • Strawberry Tongue • Treatment:

– Pen VK – Amoxocilin – Macrolides for PCN allergy

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Contact Dermatitis • Can be caused by

allergens • More commonly caused

by irritants – Detergents, soaps,

chemicals, cold air • May be chronic exposures

or isolated accidental exposure

• Severe reactions can lead to necrosis and ulceration

Atopic Dermatitis AKA Eczema

• Atopic Triad – Dermatitis, Asthma, Hay

fever • Presentation

– Affects hands, feet antecubital and popliteal fossae, postt neck wrist and ankles

– Erythematous, pruritic, scaly patches

– Chronic atopic dermatitis • Hyperpigmentation,

lichenifications and fissuring

• Remove offending agents – antihistamines,

antibiotics and anti-itch creams (cause secondary allergy)

– Lubricate: petroleum jelly, thick ointments

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Psoriasis

• Palms and soles are common – Also affects elbows, knees, scalp, umbilicus and

gluteal cleft • May need biopsy to diagnosis • Treatment

– High or ultrahigh potency topical corticosteroids such as fluocinonide, clobetasol propionate or betamethason dipropionate ointment

– Topical lubricants

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Sebaceous Cyst

Blockage of the duct of the sebaceous gland leads to a glandular cyst

Can exist for long period of time without becoming infected

If bacterial invasion abscess formation

Erythematous, tender, fluctuant

I&D abscess (attempt to remove capsule as well)

Will help avoid recollection

REFERENCES

• Tintanilli 1599-1669, 912, 916, 1023