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Those Bumps aren’t Moguls

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1 Those Bumps aren’t Moguls
Those Bumps aren’t Moguls! An Algorithmic Approach to Rashes David Robinson MD Department of Emergency Medicine University of Texas Medical School at Houston 31rst Annual Emergencies in Medicine Conference Park City, Utah

2 General ‘Bump’ Terms Rash: An eruption on the skin; more extensive than a single lesion Lesion: Single small, diseased area Macule: Circumscribed area of change without elevation Papule: Solid raised lesion ≤1 cm Plaque: Circumscribed elevated confluence of papules ≥1 cm Nodule: Solid raised lesion ≥1 cm Pustule: Circumscribed area containing pus Vesicle: Circumscribed fluid-filled area ≤1 cm Bulla: Circumscribed fluid-filled area ≥1 cm Petechia: Small red/brown macule ≤1 cm that does not blanche

3 4 Major Rash Algorithms a. Erythematous b. Vesiculo-bullous c. Petechiae/Purpura d. Maculopapular

4 Your working at ABEM general when…
‘sick baby with red skin in room 5’ Red Skin, ‘skin is peeling off – when I push on it’, blisters Fever The 2 key historical points?

5 Erythematous Rashes Erythema (from the Greek erythros, meaning red) is redness of the skin, caused by hyperemia of the capillaries in the lower layers of the skin

6 Erythematous Rash Erythematous Rash Yes Staphylococcal SSS (children)
TEN (adults) No Kawasaki disease Scarlet fever TSS TEN Anaphylaxis Scombroid Poisoning Alcohol Flush Type of rash? Fever? Nikolsky sign Special Finding?

7 Erythematous Rash with fever Positive Nikolsky Sign – the sick ones
Staph SSS (children <5) Aka dermatitis exfoliativa neonatorum Diffuse scarlatiniform erythema No mucous membranes Shallow skin cleavage TEN (adults) MC associated with sulfa drugs First around face/eyesshoulders and UE Mortality 30-35%

8 Erythematous Rash with fever No Nikolsky sign
Toxic Shock Syndrome Diffuse erythematous rash Kawasaki Disease High fever x 5 days Red eyes, Cracked lips, Dry tongue Scarlet Fever Pink-red ‘sandpaper’ rash Flushed face, strawberry tongue Follows sore throat or impetigo

9 Erythematous Rash Erythematous Rash Yes Staphylococcal SSS (children)
TEN (adults) No Kawasaki disease Scarlet fever TSS TEN Anaphylaxis Scombroid Poisoning Alcohol Flush Type of rash? Fever? Nikolsky sign Special Finding?

10 Erythematous Rash, No Fever and No Nikolsky Sign
Anaphylaxis 2 or more body systems Scombroid poisoning Spoiled dark fleshed fish Intense histamine reaction min after ingestion Flushing, headache, abd cramps Self limited, antihistamines Alcohol Flush MC seen in Asians (East) Self limited

11 Erythematous Rash, +/- Fever and (+) Nikolsky Sign
Toxic Epidermal Necrolysis (TEN) Associated with drugs Life threatening shearing of epidermis from dermis in more than 30% of body Affects mucous membranes TX: plasmaphoresis, IVIG, stop drug, ICU admit Toxic epidermal necrolysis is a rare and usually severe adverse reaction to certain drugs. History of medication use exists in over 95% of patients with TEN.[2] The drugs most often implicated in TEN are antibiotics such as sulfonamides, nonsteroidal anti-inflammatory drugs, allopurinol, antimetabolites (methotrexate), antiretroviral drugs, corticosteroids, chlormezanone (anxiolytic) and anticonvulsants such as phenobarbital, phenytoin, carbamazepine, and valproic acid.[2]

12 A two-fer… Bed 3 Bed 9 6 yo with fluid filled vesicles on face, scalp, torso, upper arms Fever unvaccinated 60 yo with sharp back and chest pain Blisters over specific area of chest – follows dermatome No fever ‘chick peas’, ‘itching-pox’, chicken pecks What are the diagnostic clues ? Fever and rash distribution

13 Vesiculo-Bullous Rash
Definitions: Circumscribed fluid filled sac less than 1 cm (vesicle) or greater than 1 cm (bullous) Bullous erythema multiforme Hand, foot and mouth Vesicles of Hand, foot and mouth

14 Vesiculo-Bullous Rash
Yes Localized Necrotizing fasciitis Hand, Foot, and Mouth Diffuse Varicella/Chicken Pox Small Pox Disseminated GC Purpura Fulminans/ DIC No Bullous Pemphigus Pemphigus Vulgaris Contact Dermatitis Zoster Burns Dyshidrotic Eczema Type of rash? Fever? Special Finding? Distribution

15 Vesiculo-Bullous rash Febrile and Localized
Necrotizing Fasciitis Rapidly progressing Polymicrobial, gpA strept IV ABX Hand, Foot and Mouth Children <10 Coxsackie A16 Vesicles to hands, feet Symptomatic tx

16 Vesiculo-Bullous rash Febrile and Diffuse
Varicella/ Chicken pox Smallpox Variola v Born after 1972? Disseminated GC Also seen as palpable purpura Purpura Fulminans / DIC Fever, shock, rapid SQ hemorrhage, tissue necrosis, DIC MC meningococcal or G(-) organisms Trauma, multiorgan failure

17 Vesiculo-Bullous Rash
Yes Localized Necrotizing fasciitis Hand, Foot, and Mouth Diffuse Varicella/Chicken Pox Small Pox Disseminated GC Purpura Fulminans/ DIC No Bullous Pemphigus Pemphigus Vulgaris Contact Dermatitis Zoster Burns Dyshidrotic Eczema Type of rash? Fever? Special Finding? Distribution

18 Vesiculo-Bullous rash Not Febrile and Localized
Contact Dermatitis Often linear at point of irritation Zoster VZV Follows dermatome pattern Burns Dyshidrotic Eczema Pruritic blisters on hands and feet, possibly scaly Unknown etiology Dyshidrotic eczema: tx with heavy ointments (petrolium jelly), ?topical steroids

19 Vesiculo-Bullous rash Not Febrile and Diffuse
Bullous Pemphigus (~60s) Neg Nikolsky’s, pruritic Oral lesions in 1/3 Pemphigus Vulgaris (>40 y) Autoimmune blistering of skin (flaccid bullae) and mucous membranes Penicillamine, ACE inh Treat as burns, immunosuppressant therapy Tx: dapsone, steroids, gold?, azathioprine, methotrexate, cyclosporin. ?plasmapheresis

20 Hey Doc…I got these Bumps on my skin
Afebrile What are the distinguishing features for these ‘bumps’ Are they Bumps? Palpable or Nonpalpable? Do they Blanch?

21 Petechial / Purpuric rash
Petechia: small (< 3 mm) red or purple spot on body due to minor hemorrhage of blood vessel Purpura: Larger hemorrhagic lesions (3-10mm) Ecchymosis: largest (>10mm)

22 Petechial / Purpuric rash
Yes Palpable Meningiococcemia Disseminatd GC Endocarditis RMSF HSP Not palpable TTP Purpura Fulminans/DIC No ITP Vasculitis Type of rash? Fever? Special Finding? Palpable?

23 Petechial / Purpuric rash Febrile and…
Palpable Meningococcemia Hemorrhagic, petechial with bullae From endotoxin release Disseminated GC Endocarditis Osler’s nodes, roth spots, palpable purpura RMSF Early: Small, flat non-pruritic macules on wrists forearms and ankles Late: spreads to trunk, petechial HSP Kids (2-10) Vascular palpable purpura Assoc. GI and joint pain

24 Petechial / Purpuric Febrile and Not Palpable
TTP Microangiopathic hemolytic anemia, neurologic sx, HUS Tx with plasma exchange, immunosuppressants 2° TTP assoc with ca, platelet agg inh, immunosuppresants, HIV, SLE Purpura Fulminans / DIC Associated with G- sepsis Debridement, eschar/amput often necessary HSP (anaphylactoid purpura) Systemic vasculitis, children Associated with infection (pharyngitis) Triad: purpura, arthritis, abd pain before effective treatment with plasma exchange, the fatality rate was about 90%. With plasma exchange, survival at six months is around 80%. Immunosuppressants, such as glucocorticoids, rituximab, cyclophosphamide, vincristine, or cyclosporine may also be used if there is relapse or recurrence following plasma exchange.[4] Cancer Bone marrow transplantation Pregnancy Medication use: Quinine Platelet aggregation inhibitors (ticlopidine, clopidogrel, and prasugrel) Immunosuppressants (cyclosporine, mitomycin, tacrolimus/FK506, interferon-α) HIV-1 infection PF/DIC: Common causes are severe infection (especially with meningococcus, and Capnocytophaga canimorsus, and other Gram-negative organisms),[4] and deficiency of the natural anticoagulants protein C or protein S in the blood.[5] In some cases, a cause is never found.[4]

25 Petechial / Purpuric rash
Yes Palpable Meningiococcemia Disseminatd GC Endocarditis RMSF HSP Not palpable TTP Purpura Fulminans/DIC No ITP Vasculitis Type of rash? Fever? Special Finding? Palpable?

26 Petechial / Purpuric rash Not Febrile and…
Palpable Not Palpable Vasculitis Vascular damage to capillary sized vessels ITP (idiopathic thrombocytopenic purpura) Autoimmune in 60% ½ new cases in children, 70% end in remission Most often these antibodies are against platelet membrane glycoproteins IIb-IIIa or Ib-IX, and are of the immunoglobulin G (IgG) type. ITP tx with steroids, IGG, h.pylori eradication may help, platelet transfusion not successful, tx platelets<20,000 secondary causes (usually 5–10 percent of suspected ITP cases) should be excluded.  Secondary causes could be leukemia, medications (e.g., quinine, heparin), lupus erythematosus, cirrhosis, HIV, hepatitis C, congenital causes, antiphospholipid syndrome, von Willebrand factor deficiency, onyalai and others.[2][9]  In approximately one percent of cases, autoimmune hemolytic anemia and ITP coexist, a condition referred to as Evans syndrome.[9]

27 What are these bumps? Macule: Circumscribed area of change without elevation Papule: Solid raised lesion ≤1 cm Nodule: Solid raised lesion ≥1 cm Plaque: Circumscribed elevated confluence of papules ≥1 cm Morbilliform: has both macular and papular features Drug eruption Pityriasis

28 Maculopapular Rash Fever / ill? other finding? Special Finding?
Yes Central Viral exanthum Lyme Disease (erythema migrans) Peripheral Target lesions? Yes: SJS, EM No: Meningococcemia RMSF Syphilis Lyme disease (erythema migrans) No Drug reaction Pityriasis Lesion Distribution? Flexor: Scabies, Eczema Extensor: Psoriasis Type of rash? Fever / ill? Special Finding? Distribution? other finding?

29 Maculopapular Rash and Fever
Yes Central Viral exanthum Lyme Disease (erythema migrans) Peripheral Target lesions? Yes: SJS, EM No: Meningococcemia RMSF Syphilis Lyme disease (erythema migrans) No Drug reaction Pityriasis Lesion Distribution? Flexor: Scabies, Eczema Extensor: Psoriasis Type of rash? Fever / ill? Special Finding? Distribution? other finding?

30 Maculopapular Rash with Fever and Central distribution
Viral exanthum From Gr: ‘breaking out’ Measles, rubella, erythema infectiosum, roseola… Lyme Disease (erythema migrans) Target lesions (EM) 3-30 d after bite Progresses to neuro (10-15%), cardiac complications Borrelia is transmitted to humans by the bite of infected ticks belonging to a few species of the genus Ixodes ("hard ticks").[5] Early symptoms may include fever, headache, fatigue, depression, and a characteristic circular skin rash called erythema migrans (EM). Left untreated, later symptoms may involve the joints, heart, and central nervous system.

31 Maculopapular Rash with Fever and Peripheral Distribution
Target Lesions No Target Lesions Stevens-Johnson Syndrome (SJS) Caused from drugs, infections, malignancies Erythema multiforme Meningococcemia RMSF Syphilis Lyme Disease Both diseases can be mistaken for erythema multiforme.[citation needed] Erythema multiforme is sometimes caused by a reaction to a medication, but is more often a type III hypersensitivity reaction to an infection (caused most often by Herpes simplex) and is relatively benign. Clinical presentation, history, and presence of toxicity or neurologic deficits will clue the practitioner to the correct diagnosis

32 Maculopapular Rash and No fever
Yes Central Viral exanthum Lyme Disease (erythema migrans) Peripheral Target lesions? Yes: SJS, EM No: Meningococcemia RMSF Syphilis Lyme disease (erythema migrans) No Drug reaction Pityriasis Lesion Distribution? Flexor: Scabies, Eczema Extensor: Psoriasis Type of rash? Fever / ill? Special Finding? Distribution? other finding?

33 Maculopapular Rash No Fever and Central Lesions
Drug Reaction Fixed or centrally located Pityriasis rosea Assoc. with URI, ha, n,v Herald’s Patch (2-10 cm oval red) seen Last 6 weeks Pityriasis (6%) seen on extremtys, pruritic

34 Maculopapular Rash No Fever and Peripheral Lesions
Lesions on Flexor Surfaces Lesions on Extensor Surfaces Scabies Eczema Psoriasis Immune mediated, pruritic Red and white scaly plaques, patches 30% with arthritis Tx with ointments, cr, phototherapy Psoriasis: Medicated creams and ointments applied directly to psoriatic plaques can help reduce inflammation, remove built-up scale, reduce skin turn over, and clear affected skin of plaques. Ointment and creams containing coal tar, dithranol (anthralin), corticosteroids like desoximetasone (Topicort), fluocinonide, vitamin D3 analogues (for example, calcipotriol), and retinoids are routinely used.

35 Bonus clues to bump identification
Clues to Diagnosis Rash Patient Age 0 to 5 years: Meningococcemia, Kawasaki disease, viral exanthem >65 years: Pemphigus vulgaris, sepsis, meningococcemia, TEN, SJS, TSS Rash Characteristics Diffuse erythema: Staphylococcal SSS, staphylococcal or streptococcal TSS, necrotizing fasciitis Mucosal lesions: EM major, TEN, SJS, pemphigus vulgaris Petechiae/purpura: Meningococcemia, necrotizing fasciitis, vasculitis, DIC, RMSF Symptom Hypotension Meningococcemia, TSS, RMSF, TEN, SJS

36 Key Summary Points Rash with fever is a bad thing
Organize rashes to the 4 major types: erythematous macular/papular petechial/purpura vesicular-bullous Secondary signs (Nikolsky, distribution, location (peripheral vs central, extensor vs flexor)

37 Now, go hit those bumps

38 References and Acknowledgments
Hanson, S, Nigro, J. Pediatric Dermatology. Medical Clinics of North America. 82(6): , 1998 Lampell, MS.Childhood Rashes that Present to the ED. Pediatric EM Practice. EBMedicine.net 4:3,2007 CDC homepage (www.cdc.gov/meningitis) Papulosquamous Diseases. dermatitis emedicine.medscape.com/article/ overview Murphy-Lavoie, HM. “Approach to Rashes”. Notes from lecture Oct 27, ACEP Scientific Assembly Special thanks to Dr. Ronald Rapini, MD Chair, Dermatology at University of Texas Medical School at Houston for various photos


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