Transcript Acute Skin Conditions

Drug Eruptions/Skin
Emergencies/Signs of
Systemic Disease
Dr Nagla Konbor
University Hospitals Coventry and
Warwickshire NHS Trust
Objectives
 Drug eruptions
 Skin emergency
 Skin signs of internal malignancy
 Skin signs of internal disease
other than malignancy
Urticaria
 A flesh-coloured to pink, well circumscribed plaque caused
by dermal oedema
 Itchy!
 Individual lesions last only a few hours, usually resolved
within 24 hours
 When caused by drugs, may be IgE mediated, triggering
mast cell granule release; or drug may directly cause mast
cell granule release
Exanthem/Morbilliform Eruption
 “Morbilliform" refers to a resemblance to the
rash of measles (morbilli is Latin for
measles)
 Symmetrically distributed on the trunk and
proximal extremities, and consists of bright
pink macules and slightly raised papules
("maculopapular")
Fixed drug eruption
 “Fixed" in that it occurs at same sites with
each episode
 OTC drugs containing phenolphthalein,
pseudoephedrine, etc. common culprits
 Tetracyclines, barbiturates, phenothiazines,
sulfonamides
 Oval, itchy or burning dusky red plaque
Erythema Multiforme
 Range of illness from EM minor to EM major/StevenJohnson Syndrome to Toxic Epidermal Necrolysis
 Cell-mediated immune reaction, vasculitis
 Rash range from iris/target lesion, to erythematous
maculopapular rash, urticaria, and vesicobullous
 Dorsum of hands and feet and extensor surfaces
EM Minor
 Acute self-limited eruption
 Many causes
– medications (anticonvulsants, sulfa drugs,
chemo agents, NSAID’s)
– infectious (Mycoplasma, Herpes)
 Limited mucosal involvement and limit organ
involvement
Steven-Johnson Syndrome
 EM major
 < 10% body surface area
 More severe with more mucosal
involvement than EM minor
 5-15% mortality
 Treatment: treat underlying cause (stop
offending medication, valacyclovir),
immunosuppression (cyclophosamide,
prednisone, cyclosporin), usually supportive
Toxic Epidermal Necrolysis (TEN)
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TEN is a medical emergency!
> 30% body surface area
May represent severe form of SJS
Up to 70% mortality rate
Generalized epidermal sloughing with
mucosal involvement
 Warm tender erythroderma, vesicles/bulla
exfoliation
 + Nikolsky sign
 Hemorrhagic crusting of the lips
 Conjunctivitis common
 Medications induced, infectious, or
idiopathic
 Treatment: supportive, removing offending
agents, antibiotics for signs of infection, pain
control
Staphylococcal Scalded Skin
Syndrome (SSSS)
 Lyell’s disease
 Caused by epidermolytic exotoxin from a
group 2 staphylococcus (phage-type 71)
 Toxic, crying, pyrexial
 Burning of skin which is tender to touch
 Widespread desquamation of the epidermis,
periorbital, perioral and flexural
 Early recognition and systemic antibiotic can
be life-saving
Meningoccemia
 Neisseria meningitidis
 Seasonal prevalence (winter and early
spring)
 Early symptoms – fever, petechial rash,
irritability
 Later symptoms – lethargy, shock, DIC,
purpura, thrombosis
 Treatment – antibiotic and corticosteroid (if
in shock and diagnosed early)
Necrotizing Fasciitis
 Polymicrobial infection - spreads along
superficial and deep fascial planes
 Causes vascular occlusion, ischemia, and
tissue necrosis
 Mortality up to 25%
 Prodrome of fever and chills, followed by
erythroderma and a vesicobullous rash
 Treatment – Abx, surgical debridement
Heparin induced necrosis
Coumarin Necrosis
Skin Signs of Internal Malignancy
 Cutaneous metastases
 Paraneoplastic syndromes
 Heritable "cancer syndromes"
Sister Mary Joseph nodule
 Umbilical metastasis; poor prognosis
 Precedes or follows diagnosis of CA
 CA sites (decreasing order of frequency):
colon, ovary, pancreas, endometrium,
breast, small bowel
Paraneoplastic Syndromes
 The skin often presents a clue that an
internal malignancy is present.
 The combination of a malignancy and
associated signs and symptoms that are
seemingly unrelated to the actual tumour is
called a "paraneoplastic" syndrome.
Erythema Gyratum Repens
 “Wood-grain" pattern
 Wavy, erythematous, urticarial bands with
scale
 Slowly migrate
 Breast, stomach, bladder, prostate, cervix;
occasionally no CA
Necrolytic Migratory Erythema
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Glucagonoma
Occasionally no neoplasm found
Abdomen, thighs and buttocks
Patchy erythema with flaccid vesicles and
bullae
 Glossitis, angular cheilitis, normocytic
anemia, low amino acid levels in serum
Heritable “Cancer Syndromes"
Peutz-Jehger syndrome
 Multiple hamartomatous polyps in small
bowel (most common), stomach and colon;
low risk of bowel malignancy
 Multiple lentigines (freckle-like) of lips, nose,
oral mucosa, fingertips and nail beds
 Non-intestinal malignancies increased: lung,
ovary, endometrium pancreas, myeloma
Skin signs of internal disease
other than malignancies
Necrobiosis Lipoidica
 Well-circumsribed, firm, depressed, waxy,
yellow-brown, lesions on the skin
 Usually on the shin. 85% on the legs
 60% of NL has diabetes mellitus
 20% of NL has impaired glucose tolerance
or a family history of diabetes
 Treatment: triamcinolone injection etc
Pyoderma Gangrenosum
 Characteristic rapidly expanding ulcer with bluish
undermined border; often lower extremities; begin as
sterile pustules
 50% no disease association
 1% to 10% of patients with active ulcerative colitis; often
(but not always) parallels disease
 Other disease associations: Crohn’s, chronic active
hepatitis, rheumatoid arthritis, HIV infection; acute and
chronic granulocytic leukemia (bullous PG)
 Can be associated with underlying malignancy (leukemia,
etc.)
Xanthomas
 May be a sign of systemic metabolic abnormality
or a local cellular dysfunction
 Xanthomas may be the first sign of one the
hyperlipoproteinemias, rare but serious metabolic
diseases
 Xanthelasma are xanthomas of eyelids that may
or may not be associated with hyperlipidemia
 Eruptive xanthomas, tendon xanthomas, and
tuberous xanthomas are signs of significant
hyperlipidemia; these patients require careful
evaluation and prompt treatment
Acanthosis Nigricans
 Velvety thickening and darkening
(hyperpigmentation) of the skin, especially on the
nape of the neck, axillae and other body folds
 Underlying causes may be hereditary or acquired,
and include:
– obesity; drugs; "malignant" acanthosis nigricans; hereditary, benign
AN
 Hyperinsulinemia is a common denominator
Erythema Nodosum
 Deep erythematous painful nodules, symmetrically
on the lower legs; female predominance; a
hypersensitivity panniculitis
 Fever, chills, malaise, leukocytosis
 Disease associations: streptococcal infections,
drugs (OCPs, sulfonamides, iodides), pregnancy,
TB, deep mycoses, acute sarcoidosis,
inflammatory bowel disease
Telogen Effluvium
 A distinctive form of hair loss that is a response to
an underlying systemic condition
 Normally, about 50-100 telogen hairs are shed
from the scalp each day; in telogen effluvium, this
number is greatly increased
 The telogen hairs start falling out about 3 months
after a "precipitating event--" major surgery,
severe illness, certain drugs, and childbirth being
the most common. Chronic disease or drug
ingestion can cause a sustained telogen effluvium-e.g., hypothyroidism, retinoid use
Erythema Chronicum Migrans
 Often the first manifestation of Lyme disease
 Spirochete Borrelia burgdorferi is transmitted by the bite of
the deer tick Ixodes scapularis in the northeastern U.S.
(other species elsewhere)
 Systemic borreliosis is a potentially serious disease,
causing both acute and chronic symptoms such as fever,
malaise, arthralgia, carditis, arthritis, meningitis, etc.
 Typical lesion is a macule or papule that expands over
several days, with central clearing, to form an annular,
erythematous patch or plaque; may reach 15 or more CM
in size
 Soldiers and Marines hiking through fields in endemic
areas are prone to this disease
Leukocytoclastic Vasculitis
 “Palpable purpura," small, raised areas of
cutaneous hemorrhage and inflammation at
the site of venular destruction
 May be associated with fever, joint pain, and
internal organ damage (kidneys, GI tract,
brain)
 Lesions are usually numerous and tend to
affect the legs and ankles most severely
 Causes
 Drugs, such as sulfonamides, penicillins, others
 Infections, such as Group A streptococcal, viral
hepatitis (e.g. Hep. C), others
 Immunologic diseases such as systemic lupus
erythematosus, rheumatoid arthritis,
cryoglobulinemia
 Neoplasms such as lymphomas
 Idiopathic--no cause found in @50% of cases
Thank You
 Any questions?