Dermatological presentations to emergency

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Chapter 40 Dermatological presentations to emergency

John R. Sullivan, Veronica A. Preda, Margot J. Whitfield

Dermatology presentations to emergency department are common, accounting for 15–20% of visits,¹ with the majority of presentations due to an infective aetiology or the result of drug reactions. Overall, there are four basic categories of dermatological presentation to emergency department (see Table 40.1).

Table 40.1 Isolated dermatological disorders

Reason for presentation	Common or important clinical examples
New onset or flare	Eczema (atopic dermatitis)Papular urticaria—mainly a paediatric emergency presentation usually representing an exaggerated local hypersensitivity to an insect bite which can be clinically dramatic and/or severe, such as a blistering skin reaction
Subacute or chronic with complication	Impetiginised scabies, eczema
Dermatological presentations with systemic associations
Fifth disease	Pregnant woman—increased risk of hydrops fetalis or aplastic crisis if underlying haematological disorder
Systemic disorders resulting in acute presentations with prominent cutaneous manifestations
SLE/PAN/cholesterol emboli	Vasculitis, trash foot, broken livedoid eruption
Systemic disorders with associated cutaneous changes or disorders
Inflammatory bowel disease and/or inflammatory arthritis	Pyoderma gangrenosum
Systemic disorders with unrelated/incidental cutaneous findings
Common presentations	Seborrhoeic dermatitis (> 50% elderly but also more common in particular clinical settings, e.g. advanced HIV/AIDS, neurological disorders, especially Parkinson’s disease)

HIV/AIDS, human immunodeficiency virus/acquired immune deficiency syndrome; PAN, polyarteritis nodosa; SLE, systemic lupus erythematosus

Table 40.2 Terminology for skin lesions

Lesion	Description
Bulla(e)	Large fluid-filled lesion > 0.5 cm in diameter
Cyst	Closed cavity/sac with epithelial lining containing solids or fluids
Discoid	Disc-shaped (nummular)
Erythema	Redness of the skin from vascular congestion or increased flow such as in inflammation
Macule	Flat alteration in colour and/or texture of the skin, e.g. colour change due to skin inflammation including erythema and/or hyper/hypopigmentation (change in melanin, haemosiderin); if larger than several centimetres, referred to as a patch
Nodule	Solid mass > 0.5 cm in diameter, palpable
Papule	Solid elevation of the skin < 0.5 cm in diameter
Petechiae	Pinpoint, flat, round, purplish red spots caused by intradermal or submucosal haemorrhage
Plaque	Solid, elevated lesion; may be formed by coalescence of papules
Purpura	Bleeding into the dermis; may be macular or papular
Pustule	Circumscribed collection of pus, commonly staphylococcal, but may be sterile in inflammatory and autoimmune dermatoses, e.g. pustular psoriasis
Telangiectasia(e)	Tiny visible blood vessels in the upper dermis ± inflammation
Verrucous	Rough, warty
Vesicle	Visible accumulation of fluid within or beneath the epidermis, < 0.5 cm
Wheal	Transient area of dermal oedema, pale, compressible, papular or plaque-like

Surface characteristics: scale, crust, horn, excoriation, maceration, lichenification

Table 40.3 Diagnosis of dermatological disease

Diagnosis
Accurate characterisation of skin eruption	E.g. exanthematic eruption, skin rash due to or mimicking a viral infection
Isolated skin presentation versus any worrisome systemic involvement; concerning symptoms or associated findings	E.g. high fever (> 40°C) or ‘sick’ patient presentation
Differential diagnosis
	Infection: viral, bacterial, fungalDrug eruption: isolated (simple) exanthematic hypersensitivity reaction (and/or the manifestation of a systemic hypersensitivity reaction)Connective tissue disease, graft versus host disease (due to an acute disease flare and/or active inadequately controlled disease)
Drug and other exposures
Medications history	When medications, including over-the-counter and alternative or natural therapies, were started and/or stopped; any previous reactions to similar or crossreacting medications, vaccinations or injections
Other exposure	IVDU, environmental exposure, history of infective symptoms, travel
Diagnostic testing
Diagnosis	Most diagnoses are suspected in emergency but confirmed at a later date. e.g. drug reactions largely a diagnosis of exclusion
Differential diagnosis	May require baseline (acute) viral and autoimmune serologyALWAYS perform a bacterial culture for M/C/S if itchy/weeping/crusted/purulent, ± viral culture if painful
Associated diseases/toxicities/complications	E.g. hepatitis, nephritis as part of a drug hypersensitivity syndrome and/or connective tissue disease flare. Drug hypersensitivity reactions are more common in those living with HIV/AIDS, lymphoma ± CTD
Determine probabilities
Paediatric	Infectious aetiology more likely
Adult	Consider comorbidities and always consider drug causes, especially in the elderly
Dermatologist consult
Urgent	E.g. suspected SJS/TEN
Organise follow-up/discuss

CTD, connective tissue disease; IVDU, intravenous drug use; M/C/S, microculture and sensitivity; SJS, Stevens-Johnson syndrome; TEN, toxic epidermal necrolysis

Table 40.4 Infective complications of dermatoses in immunocompetent patients

Bacterial	Staphylococcus aureus (approximately 90%) Always consider risk factors for methicillin resistant S. aureus (MRSA) Streptococcus pyogenes Always consider nephritogenic strain, especially in Indigenous populations Mixed
Viral	Herpes simplex virus 1, 2
Fungal	Trichophyton rubrum and T. tonsurans (especially in rural and remote Indigenous populations)

Table 40.5 Assessing patients with dermatological emergency presentations

Dermatological history

Note: Take advantage of being able to readily and concurrently evaluate and examine the skin early in the consultation process to assist in the provision of an expedient and clinically focused and relevant medical assessment.

Where: site(s) of initial lesion, then subsequent lesions

Associated dermatological symptoms: e.g. irritable, pruritic, burning or tender skin

Temporal disease course/exposures:

• onset/duration—acute, exacerbation of a chronic or intermittent condition

• recent medication and medical history (weeks–months)

• travel (rural/farm or overseas)

• change in symptoms over time

Any other family members/colleagues/school friends affected

Personal and family history of skin disease

Cutaneous changes warning of a potentially severe cutaneous reaction/disease and/or systemic reaction/disease, such as a previously itchy skin eruption that becomes tender and/or blisters

Other dermatological symptoms and manifestations suggesting/warning of associated mucosal involvement preceding, coinciding or following onset of skin changes (e.g. sore throat/pharyngitis, gritty eyes/periorbital puffiness or head and neck swelling/enlarged cervical glands)

Presence or absence of associated symptoms suggesting skin involvement by a systemic disease/associated internal organ involvement/toxicity (e.g. high fever/night sweats, anorexia, arthritis)

Occupational history (e.g. a possibly infective presentation and work history exploring animal exposures) and/or work/close contact with an elderly family member living in a nursing home (e.g. if scabies considered in a patient with an acute/subacute ± itchy skin reaction)

Home environment/activities: blistering, extremely itchy, streaky inflammatory eruption mainly and most severely involving upper limbs and other exposed skin areas starting hours after gardening

Treatments tried and any associated temporal changes in disease symptoms

Examination

Dermatological: distribution, morphology, pattern

Where relevant, also examine mucosal surfaces e.g. for oropharyngeal inflammation/erosion/ulceration

General examination (tailor and target to presentation as illustrated by the following examples):

• Arterial examination including abdominal examination specifically checking for an acutely dissecting abdominal aortic aneurysm as the source of cholesterol emboli in a person presenting with lower back pain and a tender, dusky, ischaemic reticulate lower leg eruption

• Examination for presence or absence of tender lymphadenopathy of draining lymph nodes with cutaneous infections and/or an infective complication of skin disease

MORPHOLOGICAL CLASSIFICATION OF DERMATOLOGICAL PRESENTATIONS

1 Urticaria (hives) ± angio-oedema ± anaphylaxis

• Cutaneous versus systemic reaction.

• Common condition: 15–25% of people have an episode of urticaria ± angio-oedema at some stage in their life. Usually it is acute.²

Flow diagram: adapted from Amar and Dreskin²

Table 40.7 Medications in angio-oedema, anaphylaxis and acute and ‘subacute’ urticaria

Medication	Recommended adult dose	Comment
Adrenaline	0.5–1.0 mL of 1:1000 IM	Used if evidence ofanaphylaxis
H₁ antihistamine Chlorpheniramine Diphenhydramine

4 mg q4–6 h, max 24 mg/day

Mainstay of therapy

Sedating in 50% patients

H₁ antihistamine, 2nd generation

Reasonable to continue antihistamines for approximately 72 hours after acute presentation

Although caution required, medications are safe in general long-term and can be used in higher doses for urticaria

Steroids

Hydrocortisone

Prednisone

100 mg IV

1 mg/kg in divided doses and taper

Acute severe episodes, avoid chronic use, especially in patients with chronic urticaria

Table 40.8 Treatment of chronic urticaria (often a distressed patient with chronic symptoms presenting with a flare)

Simple measures	Keep cool, loose clothing
H₁ antihistamine Chlorpheniramine Diphenhydramine	4mg q4–6 h, max 24 mg/day	Mainstay of therapy Sedating in 50% patients
H₂ antihistamine Ranidine Cimetidine Famotidine	150 mg BD 400 mg BD 20 mg BD	Useful in chronic urticaria in addition to H1 antihistamines
Cyproheptadine	4 mg TDS	Sedating antihistamine plays an important role in chronic urticaria, e.g. with nocturnal exacerbations or insomnia due to urticaria, and appetite stimulant
Doxepin	10–50 mg/day	H1- and H2-blocking properties, sedating, appetite stimulant, higher doses have anxiolytic and antidepressive effects
Steroids Hydrocortisone Prednisone	100 mg IV 1 mg/kg in divideddoses and taper	Acute severe episodes, avoid chronic use, especially in patients with chronic urticaria
Other immunosuppressives	For immunologist referral

2 ‘Spotty, blanching’ exanthematic eruptions

Infection-associated skin eruption or other disease with skin changes mimicking those of an infective exanthem.

Exanthematic eruption

Generalised cutaneous eruption usually associated with a primary systemic infection, often accompanied by oral mucosal lesions (an enanthem).

Clinical features

• Lesion morphology: flat, erythematous macules or papular, less frequently vesicles, pustules petechiae and itch.

• Systemic features: consideration of the seriousness of presentation (not aetiology) to differentiate isolated ‘skin changes only’—no fever, no systemic symptoms, no systemic findings, normal lab tests—versus symptomatic—unwell with fever ± hypotension, internal organ involvement; ± lymphadenopathy ± hepatosplenomegaly.

• Associated exanthem: severe mucosal changes are predictors of serious systemic disease, e.g. oropharyngeal ulceration especially haemorrhagic changes and/or eye or genitourinary.

• Characteristic mucosal changes include:

• drug eruptions

• inflammatory disease

• Koplick spots, red strawberry tongue, mouth changes in Kawasaki’s etc.

Note: For exanthematic ‘spotty, blanching’ eruptions, ALWAYS consider the seriousness of the presentation: skin changes ± mucosal features ± systemic features, i.e. eruption plus systemically well versus eruption plus systemically unwell patient.

Investigations

• If there is suspicion of systemic involvement: full blood count (FBC), urea, electrolytes, creatinine (UEC), liver function test (LFT), C-reactive protein (CRP), urinalysis (U/A), urine microscopy

• Cultures if appropriate: blood, urine, ± lumbar puncture (LP)

• Serology: acute and convalescent titres for specific diagnosis

Differential diagnosis

Table 40.9 Differential diagnosis, exanthematic eruption

Paediatric exanthematic eruption	Adult exanthematic eruption
1. Infection-related—most commonly in children and usually well: • viral • bacterial • parasitic • fungal 2. Drugs—common nuisance drug eruptions

• Drugs ³—just about all medications but particularly:

• antibiotics

• antivirals

• anti-inflammatories

• anticonvulsants

• antipsychotics4 ⁴

• Inflammatory includes connective tissue disease; other, as part of a flare or warning of disease activity in the context of systemic illness

3. Infection-related:

• viral—including adult varicella zoster, seroconversion illness in HIV ⁵

• rickettsial infections e.g. Rickettsia australis⁶—‘recurrent mild chicken pox in an adult’

• bacterial e.g. S. pyogenes causing toxic shock syndrome

• parasitic

• fungal

Things not to miss

Meningitis—meningococcal can present atypically

Serious drug eruption

Reye’s syndrome

Kawasaki’s disease

Things not to miss

Serious drug eruption

Autoimmune causes—rheumatoid arthritis, systemic lupus erythematosus

Malignancy e.g. lymphoma

Adult varicella zoster

Kawasaki’s disease

• Mucocutaneous lymph node syndrome.

• Cutaneous features of an exanthematic eruption, with prominent peeling hands and feet. Often differential is that of an infective illness, but usually fever > 5 days unresponsive to antipyretics.

Table 40.10 Features and management of common viral exanthems in paediatric patients

Disease/virus	Signs/symptoms	Management
Enterovirus	Commonly respiratory or gastroenterology presentations ± exanthem or urticaria	Presentation dependent
Varicella—chicken pox/ Varicella zoster virus (VZV) Reactivation → herpes zoster (HZ)

Incubation 10–21 days

Mid-prodrome—pruritic vesicles that break and crust, starts centrally or facially and spreads to the extremities

New lesions appear 3–5 days, typically take 3 days to crust

Contagious 24 h prior to rash onset and until they crust.

Immunocompromised children with VZV are given VZ immunoglobulin (VZIG) within 96 h of exposure

Acyclovir for immunocompromised with disseminated VZ or HZ

Measles (rubeola)/

Paramyxovirus

Prodrome fever, malaise, coryza, conjunctivitis, cough then erythematous maculopapular rash face, trunk, legs, buccal mucosal lesions, Koplick spots

Incubation 8–12 days

Symptomatic management, contact considerations, vaccinations

Rubella (German measles)/

RNA togavirus

No prodrome during incubation 14–21days. Symptomatic, consider contacts including pregnant contacts

Roseola infantum/

HHV6

Infants 6–8 mo—high fever, relatively well; multiple pale pink macules/papules as fever breaks Supportive

Erythema infectiosum (fifth disease)/ Parvovirus B19

‘ Slapped cheeks’

Sore throat, cough, headache, nausea, fever with rash, slapped cheek appearance followed by lace-like erythema on the extremities and buttocks Supportive but consider concurrent haematological disease or pregnant exposure Scarlet fever/toxins from Streptococcus pyogenes

Commonly confused with Kawasaki’s

Child 4–8 years, high fever, sore throat, headache, vomiting

Exanthem 1–2 days post—small papules with diffuse erythema

Skin may feel rough like sand paper

Linea petechiae = pastia’s lines in the axillae and groin.

Desquamation 7–10 days post, hand and feet worse.

Strawberry tongue; lips normal; tonsils/pharynx usual site of infection ± surgical wounds

Ix: include antiDNAase B, antistreptolysin O titre

If suspected treat with penicillin, (clindamycin or erythromycin if allergic)

Management is to avoid complications, e.g. rheumatic heart disease

Mumps Morbilliform rash with lymphadenopathy, an issue in young males with potential infertility Despite vaccination consider occurrence Mycoplasma pneumoniae

Skin changes may be macular papular or present as purpura

Mainly in school children, cough, coryza

Skin eruptions in approximately 10% children with mycoplasma

Swab throat—PCR

Antimicrobial therapy for Mycoplasma, e.g. rifampicin

Hand, foot and mouth disease (HFMD)/

Enterovirus, coxsackie

Generally mild clinical course

Distinct clinical presentation of oral and distal extremity lesions

Highly contagious, faecal oral spread

Usually in children < 10 years, can affect adults

Hands, feet and buttocks involved; 2–10 mm erythematous macules, with central grey oval vesicle