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Those Bumps aren’t Moguls! An Algorithmic Approach to Rashes David Robinson MD Department of Emergency Medicine University of Texas Medical School at Houston.

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Presentation on theme: "Those Bumps aren’t Moguls! An Algorithmic Approach to Rashes David Robinson MD Department of Emergency Medicine University of Texas Medical School at Houston."— Presentation transcript:

1 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 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 Erythematous Rashes

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

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

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

12 A two-fer… Bed 3 6 yo with fluid filled vesicles on face, scalp, torso, upper arms Fever unvaccinated Bed 9 60 yo with sharp back and chest pain Blisters over specific area of chest – follows dermatome No fever 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) Vesicles of Hand, foot and mouth Bullous erythema multiforme

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

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

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

19 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 Vesiculo-Bullous rash Not Febrile and Diffuse

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 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) Petechial / Purpuric rash

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

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

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

26 Petechial / Purpuric rash Not Febrile and… Palpable Vasculitis – Vascular damage to capillary sized vessels Not Palpable ITP (idiopathic thrombocytopenic purpura) – Autoimmune in 60% – ½ new cases in children, 70% end in remission

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 Pityriasis Drug eruption

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

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

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

31 Maculopapular Rash with Fever and Peripheral Distribution Target Lesions Stevens-Johnson Syndrome (SJS) – Caused from drugs, infections, malignancies Erythema multiforme No Target Lesions Meningococcemia RMSF Syphilis Lyme Disease Clinical presentation, history, and presence of toxicity or neurologic deficits will clue the practitioner to the correct diagnosis

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

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

34 Maculopapular Rash No Fever and Peripheral Lesions Lesions on Flexor Surfaces Scabies Eczema Lesions on Extensor Surfaces Psoriasis – Immune mediated, pruritic – Red and white scaly plaques, patches – 30% with arthritis – Tx with ointments, cr, phototherapy

35 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 Bonus clues to bump identification

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)www.cdc.gov/meningitis Papulosquamous Diseases. dermatitis emedicine.medscape.com/article/ overview emedicine.medscape.com/article/ overview Murphy-Lavoie, HM. “Approach to Rashes”. Notes from lecture Oct 27,2008. 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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