Dermatological presentations to emergency

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Chapter 40 Dermatological presentations to emergency

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
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
Examination

MORPHOLOGICAL CLASSIFICATION OF DERMATOLOGICAL PRESENTATIONS

1 Urticaria (hives) ± angio-oedema ± anaphylaxis

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  
4mg q4–6 h, max 24 mg/day
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
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).

Kawasaki’s disease

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

Symptomatic management, contact considerations, vaccinations No prodrome during incubation 14–21days. Symptomatic, consider contacts including pregnant contacts Infants 6–8 mo—high fever, relatively well; multiple pale pink macules/papules as fever breaks Supportive 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 Mumps Morbilliform rash with lymphadenopathy, an issue in young males with potential infertility Despite vaccination consider occurrence Mycoplasma pneumoniae Antimicrobial therapy for Mycoplasma, e.g. rifampicin