Presentation on theme: "Those Bumps aren’t Moguls"— Presentation transcript:
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’ TermsRash: An eruption on the skin; more extensive than a single lesionLesion: Single small, diseased areaMacule: Circumscribed area of change without elevationPapule: Solid raised lesion ≤1 cmPlaque: Circumscribed elevated confluence of papules ≥1 cmNodule: Solid raised lesion ≥1 cmPustule: Circumscribed area containing pusVesicle: Circumscribed fluid-filled area ≤1 cmBulla: Circumscribed fluid-filled area ≥1 cmPetechia: Small red/brown macule ≤1 cm that does not blanche
3 4 Major Rash Algorithmsa. 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’, blistersFeverThe 2 key historical points?
5 Erythematous RashesErythema (from the Greek erythros, meaning red) is redness of the skin, caused by hyperemia of the capillaries in the lower layers of the skin
10 Erythematous Rash, No Fever and No Nikolsky Sign Anaphylaxis2 or more body systemsScombroid poisoningSpoiled dark fleshed fishIntense histamine reaction min after ingestionFlushing, headache, abd crampsSelf limited, antihistaminesAlcohol FlushMC seen in Asians (East)Self limited
11 Erythematous Rash, +/- Fever and (+) Nikolsky Sign Toxic Epidermal Necrolysis (TEN)Associated with drugsLife threatening shearing of epidermis from dermis in more than 30% of bodyAffects mucous membranesTX: plasmaphoresis, IVIG, stop drug, ICU admitToxic 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. 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.
12 A two-fer…Bed 3Bed 96 yo with fluid filled vesicles on face, scalp, torso, upper armsFeverunvaccinated60 yo with sharp back and chest painBlisters over specific area of chest – follows dermatomeNo fever‘chick peas’, ‘itching-pox’, chicken pecksWhat 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 multiformeHand, foot and mouthVesicles of Hand, foot and mouth
14 Vesiculo-Bullous Rash YesLocalizedNecrotizing fasciitisHand, Foot, and MouthDiffuseVaricella/Chicken PoxSmall PoxDisseminated GCPurpura Fulminans/ DICNoBullous PemphigusPemphigus VulgarisContact DermatitisZosterBurnsDyshidrotic EczemaType of rash?Fever?Special Finding?Distribution
15 Vesiculo-Bullous rash Febrile and Localized Necrotizing FasciitisRapidly progressingPolymicrobial, gpA strept IV ABXHand, Foot and MouthChildren <10Coxsackie A16Vesicles to hands, feetSymptomatic tx
16 Vesiculo-Bullous rash Febrile and Diffuse Varicella/ Chicken poxSmallpoxVariola vBorn after 1972?Disseminated GCAlso seen as palpable purpuraPurpura Fulminans / DICFever, shock, rapid SQ hemorrhage, tissue necrosis, DICMC meningococcal or G(-) organismsTrauma, multiorgan failure
17 Vesiculo-Bullous Rash YesLocalizedNecrotizing fasciitisHand, Foot, and MouthDiffuseVaricella/Chicken PoxSmall PoxDisseminated GCPurpura Fulminans/ DICNoBullous PemphigusPemphigus VulgarisContact DermatitisZosterBurnsDyshidrotic EczemaType of rash?Fever?Special Finding?Distribution
18 Vesiculo-Bullous rash Not Febrile and Localized Contact DermatitisOften linear at point of irritationZosterVZVFollows dermatome patternBurnsDyshidrotic EczemaPruritic blisters on hands and feet, possibly scalyUnknown etiologyDyshidrotic eczema: tx with heavy ointments (petrolium jelly), ?topical steroids
19 Vesiculo-Bullous rash Not Febrile and Diffuse Bullous Pemphigus (~60s)Neg Nikolsky’s, pruriticOral lesions in 1/3Pemphigus Vulgaris (>40 y)Autoimmune blistering of skin (flaccid bullae) and mucous membranesPenicillamine, ACE inhTreat as burns, immunosuppressant therapyTx: dapsone, steroids, gold?, azathioprine, methotrexate, cyclosporin. ?plasmapheresis
20 Hey Doc…I got these Bumps on my skin AfebrileWhat 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 vesselPurpura: Larger hemorrhagic lesions (3-10mm)Ecchymosis: largest (>10mm)
23 Petechial / Purpuric rash Febrile and… PalpableMeningococcemiaHemorrhagic, petechial with bullaeFrom endotoxin releaseDisseminated GCEndocarditisOsler’s nodes, roth spots, palpable purpuraRMSFEarly: Small, flat non-pruritic macules on wrists forearms and anklesLate: spreads to trunk, petechialHSPKids (2-10)Vascular palpable purpuraAssoc. GI and joint pain
24 Petechial / Purpuric Febrile and Not Palpable TTPMicroangiopathic hemolytic anemia, neurologic sx, HUSTx with plasma exchange, immunosuppressants2° TTP assoc with ca, platelet agg inh, immunosuppresants, HIV, SLEPurpura Fulminans / DICAssociated with G- sepsisDebridement, eschar/amput often necessaryHSP (anaphylactoid purpura)Systemic vasculitis, childrenAssociated with infection (pharyngitis)Triad: purpura, arthritis, abd painbefore 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.Cancer Bone marrow transplantation Pregnancy Medication use: QuininePlatelet aggregation inhibitors (ticlopidine, clopidogrel, and prasugrel)Immunosuppressants (cyclosporine, mitomycin, tacrolimus/FK506, interferon-α) HIV-1 infectionPF/DIC: Common causes are severe infection (especially with meningococcus, and Capnocytophaga canimorsus, and other Gram-negative organisms), and deficiency of the natural anticoagulants protein C or protein S in the blood. In some cases, a cause is never found.
26 Petechial / Purpuric rash Not Febrile and… PalpableNot PalpableVasculitisVascular damage to capillary sized vesselsITP (idiopathic thrombocytopenic purpura)Autoimmune in 60%½ new cases in children, 70% end in remissionMost 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<20,000secondary 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. In approximately one percent of cases, autoimmune hemolytic anemia and ITP coexist, a condition referred to as Evans syndrome.
27 What are these bumps?Macule: Circumscribed area of change without elevationPapule: Solid raised lesion ≤1 cmNodule: Solid raised lesion ≥1 cmPlaque: Circumscribed elevated confluence of papules ≥1 cmMorbilliform: has both macular and papular featuresDrug eruptionPityriasis
30 Maculopapular Rash with Fever and Central distribution Viral exanthumFrom Gr: ‘breaking out’Measles, rubella, erythema infectiosum, roseola…Lyme Disease (erythema migrans)Target lesions (EM) 3-30 d after biteProgresses to neuro (10-15%), cardiac complicationsBorrelia is transmitted to humans by the bite of infected ticks belonging to a few species of the genus Ixodes ("hard ticks"). 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 LesionsNo Target LesionsStevens-Johnson Syndrome (SJS)Caused from drugs, infections, malignanciesErythema multiformeMeningococcemiaRMSFSyphilisLyme DiseaseBoth diseases can be mistaken for erythema multiforme. 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 YesCentralViral exanthum Lyme Disease (erythema migrans)PeripheralTarget lesions?Yes:SJS, EMNo: Meningococcemia RMSF SyphilisLyme disease (erythema migrans)NoDrug reactionPityriasisLesion Distribution?Flexor:Scabies, EczemaExtensor:PsoriasisType of rash?Fever / ill?Special Finding?Distribution?other finding?
33 Maculopapular Rash No Fever and Central Lesions Drug ReactionFixed or centrally locatedPityriasis roseaAssoc. with URI, ha, n,vHerald’s Patch (2-10 cm oval red) seenLast 6 weeksPityriasis (6%) seen on extremtys, pruritic
34 Maculopapular Rash No Fever and Peripheral Lesions Lesions on Flexor SurfacesLesions on Extensor SurfacesScabiesEczemaPsoriasisImmune mediated, pruriticRed and white scaly plaques, patches30% with arthritisTx with ointments, cr, phototherapyPsoriasis: 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.
36 Key Summary Points Rash with fever is a bad thing Organize rashes to the 4 major types:erythematousmacular/papularpetechial/purpuravesicular-bullousSecondary signs (Nikolsky, distribution, location (peripheral vs central, extensor vs flexor)
38 References and Acknowledgments Hanson, S, Nigro, J. Pediatric Dermatology. Medical Clinics of North America. 82(6): , 1998Lampell, MS.Childhood Rashes that Present to the ED. Pediatric EM Practice. EBMedicine.net 4:3,2007CDC homepage (www.cdc.gov/meningitis)Papulosquamous Diseases. dermatitis emedicine.medscape.com/article/ overviewMurphy-Lavoie, HM. “Approach to Rashes”. Notes from lecture Oct 27, ACEP Scientific AssemblySpecial thanks to Dr. Ronald Rapini, MD Chair, Dermatology at University of Texas Medical School at Houston for various photos