Transcript How many Rashes

CONFLICT OF INTEREST
• DR. HENNESSY-HARSTAD CONFIRMS THAT SHE HAS NO CONFLICT OF INTEREST IN THIS PRESENTATION.
OBJECTIVES
• PARTICIPANTS WILL IDENTIFY SEVEN SERIOUS RASHES AND TREATMENT
• PARTICIPANTS WILL UTILIZE AN DIAGNOSTIC DECISION TREE TO IDENTIFY RASHES AND HOW TO TREAT
• PARTICIPANTS WILL IDENTIFY MEDICATIONS MOST FREQUENTLY USED FOR TREATMENT OF RASHES
• PARTICIPANTS WILL RECOGNIZE WHEN TO REFER PATIENTS TO SPECIALISTS
BY THE NUMBERS
• SKIN CONDITIONS AFFECT 20-30% OF THE POPULATION
• COST EXCEEDS $96 BILLION DOLLARS A YEAR
• 1 IN 3 PERSONS IN US ARE AFFECTED AT ANY GIVEN TIME
MISDIAGNOSIS OF RASHES
• CAN RESULT IN UNNECESSARY OFFICE VISITS
• UNNECESSARY OR WRONG PRESCRIPTIONS
• INCREASED COSTS
• PATIENT SUFFERING, DISFIGUREMENT AND EVEN FATALITY
• TIME CONSTRAINTS ARE REPORTED AS A LEADING REASON FOR MISDIAGNOSIS.
• AWAWLLDA ET AL. (2008).
WHY SO HARD TO DIAGNOSE?
• NEARLY 2,200 DISEASES AND DISORDERS AFFECTING THE SKIN
• DIFFERENT CONDITIONS BUT SIMILAR RASHES (I.E., BOTH PSORIASIS AND FUNGAL RASHES CAN APPEAR
SCALED6-9)
• SINGLE SKIN CONDITION CAN RESULT IN DIFFERENT PRESENTATIONS. FOR EXAMPLE, CONTACT
DERMATITIS MAY PRESENT WITH A VESICULAR, SCALED, PAPULAR OR MACULAR RASH.10,11
DERM EMERGENCIES
• HTTP://WWW.MIDLEVELU.COM/BLOG/DERMATOLOGIC-EMERGENCIES-7-RASHES-NPS-MUST-BE-ABLEIDENTIFY
• ANGIOEDEMA
• MENINGOCOCCEMIA
• ROCKY MOUNTAIN SPOTTED FEVER
• NECROTIZING FASCIITIS
• STEVENS JOHNSON SYNDROME (SJS) AND TOXIC EPIDERMAL NECROLYSIS (TEN)
• TOXIC SHOCK SYNDROME
• ERYTHRODERMA (GENERALIZED EXFOLIATIVE DERMATITIS)
ANGIOEDEMA
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SUBSTANTIAL LOCALIZED FACIAL SWELLING,
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50% OF PATIENTS WILL HAVE URTICARIA.
ANGIOEDEMA CAN HAVE SYSTEMIC EFFECTS.
ASSOCIATED WITH ANAPHYLACTIC REACTION
SHORTNESS OF BREATH, CHANGES IN VOICE, TONGUE SWELLING OR
THROAT TIGHTNESS AS THESE SYMPTOMS INDICATE AIRWAY
INVOLVEMENT.
HISTORY OF ACE INHIBITOAN
ALLERGEN OR THE DISEASE MAY BE HEREDITARY.
TREATMENT INVOLVES REMOVING THE OFFENDING MEDICATION OR
ALLERGEN FROM THE PATIENT'S ENVIRONMENT, ANTIHISTAMINES AND
STEROIDS. EPINEPHRINE AND SUPPORTIVE AIRWAY TREATMENT MAY
BE NECESSARY IF THE AIRWAY IS INVOLVED.
MENINGOCOCCEMIA
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PETECHIAL RASH
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THE RASH: PETECHIAE, SMALL RED SPOTS THAT DO NOT BLANCHE WITH
PRESSURE
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RASH APPEARS ANYWHERE ON THE BODY INCLUDING THE PALMS AND
SOLES OF THE FEET.
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MENINGOCOCCEMIA CAN LEAD TO MENINGOCOCCAL MENINGITIS, DIC,
SHOCK AND DEATH
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TREATMENT: AGGRESSIVE ANTIBIOTIC INTERVENTION
INITIAL PRESSENTATION: FEVER AND RASH FOLLOWED BY FATIGUE, FEVER,
HEADACHE AND BODY ACHES.
FEBRILE PATIENTS PRESENTING WITH PETECHIAL RASH SHOULD BE
SUSPECTED OF HAVING A MENGOCOCCEMIA DIAGNOSIS. BLOOD CULTURES
MUST BE DRAWN AND THE PATIENT TREATED WITH IV ANTIBIOTICS UNTIL
MENINGOCOCCEMIA IS RULED OUT WITH CULTURE RESULTS.
ROCKY MOUNTAIN SPOTTED FEVER
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CARRIED BY TICKS,
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UNTREATED PATIENTS AND PATIENTS IN WHOM THE DISEASE IS NOT
TREATED PROMPTLY HAVE A MORTALITY RATE OF 30 TO 70%.
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THE RASH : TYPICALLY APPEARS FIRST ON THE ANKLES AND WRISTS
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BEGINS AS A MACULAR RASH MANIFESTING AS FLAT, PINK SPOTS
PROGRESSING TO A RED, MORE PROMINENT PETECHIAL RASH.
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COMPLICATIONS OF RSR INCLUDE ACUTE RENAL FAILURE, HEPATIC
FAILURE, CARDIOGENIC SHOCK, DIC AND MENINGITIS
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TREATMENT: ANTIBIOTICS,
TYPICAL PRESENTATION: TRIAD OF FEVER, HEADACHE AND RASH.
PATIENTS WHO ARE ADEQUATELY TREATED HAVE A MORTALITY RATE
OF JUST 3 TO 7%
THEN SPREADS TO THE PALMS, SOLES AND EVENTUALLY THE TRUNK
AND FACE.
NECROTIZING FASCIITIS
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NECROTIZING FASCITIS IS CHARACTERIZED BY NECROSIS OF THE
SUBCUTANEOUS TISSUE AND FASCIA BY GROUP A STREPTOCOCCUS
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TYPICAL PRESENTATION:
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INITIAL SWELLING AT THE SITE FOLLOWED BY INTENSE PAIN AND TENDERNESS.
PAIN, TYPICALLY OUT OF PROPORTION TO THE EXTERNAL RASH, IS PRESENT
SYSTEMIC SYMPTOMS: FEVER, MALAISE, MYALGIA
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LARGE BULLAE OFTEN DEVELOP IS ASSOCIATION WITH THE RASH.
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EARLY IDENTIFICATION, AGGRESSIVE TREATMENT WITH ANTIBIOTICS AND
SURGICAL DEBRIEDMENT OF THE AFFECTED AREA ARE NECESSARY TO IMPROVE
SURVIVAL OUTCOME.
RISK FACTORS: DIABETES, IMMUNOSUPPRESSION
ION AND PERIPHERAL VASCULAR DISEASE.
NECROTIZING FASCITIS CAN LEAD TO GANGRENE, SHOCK AND ORGAN
FAILURE. MORTALITY IN NECROTIZING FASCITIS RANGES FROM 20 TO 80%.
STEVENS JOHNSON SYNDROME (SJS) AND TOXIC EPIDERMAL NECROLYSIS (TEN)
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SEVERE DRUG-INDUCED HYPERSENSITIVITY
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TWO OR MORE MUCUS MEMBRANES ARE TYPICALLY INVOLVED INCLUDING
THE ORAL OR BUCCAL MUCOSA AND THE GENITALIA.
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SULFA DRUGS, ANTI-EPILEPTICS AND OTHER ANTIBIOTICS ARE THE MOST
COMMON DRUGS CAUSING THESE RASHES
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OCCASIONALLY, SJS AND TEN ARE IDIOPATHIC.
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RASH TYPICALLY BEGINS TO APPEAR 1 TO 3 WEEKS AFTER TAKING THE
DRUG.
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MORTALITY RATE OF 20 TO 25%. LOSS OF EPITHELIAL TISSUE LEADS TO
SECONDARY INFECTION, FLUID LOSS AND ELECTROLYTE IMBALANCE.
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TREATMENT IS SIMILAR TO THAT OF BURNS AND IS LARGELY SUPPORTIVE.
RASH: MACULES THAT QUICKLY SPREAD AND COALESCE FORMING
BLISTERING, NECROTIC, SLOUGHING LESIONS AND DESQUAMATION.
THEORY: RESULT OF THE INABILITY OF THE BODY TO DETOXIFY DRUG
METABOLITES.
TOXIC SHOCK SYNDROME
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LIFE-THREATENING CONDITION CAUSED BY GROUP A STREPTOCOCCUS OR STAPHYLOCOCCUS
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50% OF CASES RESULT FROM SUPERABSORBANT TAMPON USE,
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PRESENTATION: 2-3 DAY PRODROME OF MALAISE FOLLOWED BY FEVER, CHILLS, NAUSEA, RASH
AND ABDOMINAL PAIN.
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THE RASH APPEARS FIRST AS ERYTHEMATOUS MACULES OR PETECHIAE FOLLOWED BY
DESQUAMATION. LOOKS LIKE A SUNBURN.
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BEGINS ON THE TRUNK AND SPREADS PERIPHERALLY TO THE EXTREMITIES, PALMS AND SOLES.
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TREATMENT INCLUDING SUPPORTIVE THERAPY AS WELL AS ANTIBIOTIC THERAPY MUST BE
INITIATED IMMEDIATELY AS TOXIC SHOCK SYNDROME HAS A MORTALITY RATE OF 30 TO 70%.
AUREUS.
OTHER CAUSES INCLUDE SURGICAL INFECTION, POSTPARTUM INFECTION, BURNS AND
OSTEOMYELITIS.
PATIENTS BECOME HYPOTENSIVE AND SUFFER FROM MULTI-ORGAN FAILURE, USUALLY IN 3 OR
MORE BODY SYSTEMS.
ERYTHRODERMA (GENERALIZED EXFOLIATIVE DERMATITIS)
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ERYTHEMATOUS, SCALING RASH COVERING AT LEAST 90% OF THE
BODY'S SURFACE.
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MOST CASES OF ERYTHRODERMA ARE IDIOPATHIC.
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PRESENTATION: DIFFUSE PRURITUS FOLLOWED BY MALAISE, FEVER,
CHILLS AND RASH.
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SCALING OF THE SKIN APPEARS 2 TO 3 DAYS AFTER ONSET OF THE
RASH.
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CAUSE: EXCESSIVE VASODILATION AND THEREFORE HYPOTENSION,
ELECTROLYTE IMBALANCE AND CONGESTIVE HEART FAILURE RESULT.
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MANAGEMENT IS LARGELY BASED ON SUPPORTIVE THERAPY
INCLUDING HYDRATION, ELECTROLYTE MONITORING AND CARDIAC
SUPPORT.
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43% MORTALITY RATE.
OTHER CAUSES INCLUDE PSORIASIS, ECZEMA, DRUG REACTION,
LEUKEMIA AND LYMPHOMA.
CATEGORIZATION OF RASHES
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INFLAMMATORY: ALLERGIC OR CONTACT DERMATITIS, ATOPIC DERMATITIS, ECZEMA, ERYTHEMA
MULTIFORME, GRANULOMA ANNULARE, LICHEN PLANUS, ROSACEA, SEBORRHEIC DERMATITIS, STASIS
DERMATITIS AND URTICARIA.
• VIRAL: HERPES, MOLLUSCUM CONTAGIOSUM, VIRAL EXANTHEMS AND WARTS
• BACTERIAL: ACNE, CELLULITIS, FOLLICULITIS, HIDRADENITIS SUPPURATIVA AND IMPETIGO
• FUNGAL: CANDIDIASIS AND TINEA
• AUTOIMMUNE: LUPUS AND PSORIASIS
• MISCELLANEOUS: ACNE NECROTICA, KERATOSIS PILARIS, MELASMA, PRURIGO NODULARIS AND
SCABIES.
VIRAL RASHES
MACULAR PAPULAR RASH
• MACULAR—FLAT AND CAN BE RED
• PAPULAR—RAISED AND CAN BE RED
• CONFLUENT—RUN TOGETHER
• DISCRETE—INDIVIDUAL LESIONS
MEASLES
VESICULAR LESIONS
• RAISED
• MAY HAVE A RED BASE
• FLUID FILLED
• CHICKEN POX
• BLISTERS SUCH AS IN SUNBURN
• BULLAE IF GREATER THAN 1 CM
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DRUG REACTIONS
STEVEN-JOHNSON
BURNS
VARICELLA—CHICKEN POX
RASH WITH SCALES
• ECZEMA
• DERMATITIS
• PSORIASIS
• TINEA
Lyons, F. (2012).
CASE STUDY
• A 57-YEAR-OLD WHITE MAN PRESENTS TO A PRIMARY CARE CLINIC WITH A RASH THAT STARTED AS RED,
ITCHY PATCHES 2 WEEKS AGO AND THEN PROGRESSED TO BLISTERS.
• HE IS EXPERIENCING DISCOMFORT FROM THE ITCHING, BUT SAYS HE IS EXPERIENCING NO PAIN.
• HE HAS TRIED MULTIPLE OVER-THE-COUNTER PREPARATIONS BUT ACHIEVED NO RELIEF.
• MR.H. HAS ERYTHEMATOUS AND VESICULAR PAPULES AND PATCHES ON BOTH FOREARMS AND THE TOPS
OF BOTH HANDS.
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HE REPORTS NO HISTORY OF RASHES OR REACTION TO MEDICATIONS EXCEPT AN ALLERGY TO
PENICILLIN, WHICH CAUSES HIVES.
Using the differential diagnostic decision
tree, the clinician notes that the rash is on
both the arms and hands and is vesicular.
The next step is to check tier 4 under "hands"
and tier 4 under "arms" for vesicular rashes.
• The differential diagnoses in tier 5 for common
vesicular rashes on the arms include
contact dermatitis
chickenpox,
• while the diagnoses for the hands include
contact dermatitis,
Lichen planus
dyshidrotic eczema.
Since the vesicular rash is not on the torso or legs,
chickenpox most likely is not the cause of this rash.
Although lichen planus and dyshidrotic eczema are
listed as occurring on the hands, they do not affect the
arms and should be eliminated as possible diagnoses.
Contact dermatitis is the logical diagnosis.
Contact dermatitis is an eczematous dermatitis caused
by exposure to substances in the environment.
The substances act as irritants or allergens and may
cause acute or subacute or chronic eczematous
inflammation.
• Clinical presentation includes erythematous
patches that may include papules, vesicles or
scales (if chronic).
• The intensity of inflammation depends
on the degree of sensitivity and the
concentration of the antigen.
• Primary care providers can use information
obtained from the history and physical to
validate the selected diagnosis.
In this case,
further questioning revealed that Mr. H. had
begun handling lubricated automotive parts at
work shortly before he developed the rash.
This fact reinforces the diagnosis of contact dermatitis.
WHAT IS THE TREATMENT?
• REMOVE THE OFFENDING AGENT
• TOPICAL STEROID CREAM OR OINTMENT
• ANTIHISTAMINE, SUCH AS BENEDRYL OR ATARAX
FREQUENTLY USED MEDICATIONS
• TOPICAL STEROIDS
• ANTIFUNGALS
• ANTIHISTAMINES
• ANTIBIOTICS
• EMOLLIENTS AND CALMING
STEROIDS
REMEMBER
• LIGHT—THIN LAYER
• LOW—POTENCY
• SHORT—DURATION
• IF USED ON A FUNGAL INFECTION—THE
INFECTION WILL GROW
ROUTES
• TOPICAL
• PO
• IV
ANTIFUNGALS
REMEMBER
• NEED A RING AROUND THE INFECTION
• PO—FOR ONE MONTH
• IDENTIFY TYPE OF FUNGUS
• NEED FOLLOW-UP
ROUTES
• TOPICAL
• CREAMS, SHAMPOOS, FOAMS, GELS
• PO—NEEDED FOR TINEA CAPITAS
• IV—SYSTEMIC INFECTION
• SUPPOSITORIES
DIRECT MICROSCOPY
• POTASSIUM HYDROXIDE (KOH) PREPARATION,
STAINED WITH BLUE OR BLACK INK
• UNSTAINED WET-MOUNT
• STAINED DRIED SMEAR
• HISTOPATHOLOGY OF BIOPSY WITH SPECIAL
STAINS, E.G., PERIODIC ACID-SCHIFF (PAS).
SPECIMEN COLLECTION--FUNGAL
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SPECIMENS FOR FUNGAL MICROSCOPY AND CULTURE MAY BE:
SCRAPINGS OF SCALE, BEST TAKEN FROM THE LEADING EDGE OF THE RASH AFTER THE SKIN HAS BEEN CLEANED WITH ALCOHOL.
SKIN STRIPPED OFF WITH ADHESIVE TAPE, WHICH IS THEN STUCK ON A GLASS SLIDE.
HAIR WHICH HAS BEEN PULLED OUT FROM THE ROOTS.
BRUSHINGS FROM AN AREA OF SCALY SCALP.
NAIL CLIPPINGS, OR SKIN SCRAPED FROM UNDER A NAIL.
SKIN BIOPSY.
MOIST SWAB FROM A MUCOSAL SURFACE (INSIDE THE MOUTH OR VAGINA) IN A SPECIAL TRANSPORT MEDIUM.
A SWAB SHOULD BE TAKEN FROM PUSTULES IN CASE OF SECONDARY BACTERIAL INFECTION.
THEY ARE TRANSPORTED IN A STERILE CONTAINER OR A BLACK PAPER ENVELOPE.
Antifungal Agent
Activity
Usual dosage
Adverse Reactions
Drug interactions
Patient Education
Clotrimazole
Candida spp.
Oral: Dissolve 1 lozenge 5
X/day for 7-14 days
Topical—daily
Intravaginal-100 to
200mg dly for 3-7 days
GI (oral); Skin
irritation; elevated
liver enzymes
Tacrolimus
Do not use with tampons
and douches. Do not use
with occlusive
dressings.
Ketoconazole
Candida spp.
Blastomyces,
Coccidioides,
Histoplasma Matassezia,
Prototheca spp.
Oral: 200-400 mg/day
Topical 1-2X daily for 2-4
weeks
GI upset;
Site irritation;
hepatotoxicity
Alprazolam; cisapride, Antacids,
anticholinergics, and H2
terfenadine,
blockers should be taken
triazolam,
Candida supp.
Cryptocuccus,
Aspergillus spp.
Blastomycaes
dermatitidis,
Histoplasma, Prototheca
spp.
Candidiasis: oral 50150 mg/day
Invasive candidiasis:
oral 6mg/kg/day
(400-800 mg/day)
Fluconazole
(Owens, Skelley, &
Kyle, 2010)
2 hours after oral
administration,
Do not wash topical
application sites for at
least 3 hours after
application.
GI disturbances,
Cisapride, rifabutin Drug interactions are
common, Take tablet
headache, elevated , triazolam,
with full glass of
liver enzymes.
warfarin
water.
Store suspension at
room temperature or
refrigerator.
AZOLE ANTIFUNGALS
GROUPS AND INDICATIONS
• TRIAZOLES AND THE IMIDAZOLES.
• TREAT SYSTEMIC INFECTIONS
• TREAT TOPICAL INFECTIONS
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. ATHLETES FOOT, RINGWORM, ETC
WHAT THEY DO
REMEMBER
• AZOLES DO NOT GET ALONG WELL WITH OTHER DRUGS (727 DRUGS—204 W MAJOR INTERACTIONS)
• HTTP://WWW.DRUGS.COM/DRUG-INTERACTIONS/KETOCONAZOLE-INDEX.HTML?FILTER=3&GENERIC_ONLY=
• SIDE-EFFECTS
• ITCHING, STINGING, BURNING, OR IRRITATION
• SWELLING OF FACE, SORES IN MOUTH, EYE REDNESS
• DISCOLORATION OF SKIN, BLISTERS—YELLOW CRUSTS; DRY OR CRACKED SKIN, PAIN OR REDNESS OF SKIN
• DIZZINESS
• BURNING, CRAWLING, ITCHNESS, NUMBNESS, PRICKLING/TINGLING FEELINGS
• WATCH FOR MICRO DOSES (GRISEOFULVIN MICROSIZE ORAL SUSPENSION)
SCALP INFECTION
ANTIHISTAMINES
• DIPHENHYDRAMINE
• TOPICAL
AND PO
• ATARAX
• LORATADINE
• GOAL—COMFORT
• DOSE AT STRONGEST
ANTIBIOTICS
THINGS TO CONSIDER
• CULTURE BEFORE STARTING
• THE PREVALENCE OF MRSA
• SHOULD START TO SEE IMPROVEMENT WITHIN
72 HOURS
ROUTES
• TOPICAL
• PO
• IV
ORAL CHOICES
• 2ND AND 3RD GENERATION CEPHLOSPORINS
• SULFAMETHOXAZOLE AND TRIMETHOPRIM (BACTRIM)
• CLINDAMYCIN
EMOLLIENTS
• SOFTEN THE SKIN
• MANY PRODUCTS ON MARKET
• EUCERIN, VANICREAM, VASOLINE,
• LARD
• STEROID OINTMENT BID FOR 7DAYS
• SEALING WATER INTO THE SKIN
OTHER
• MEDIHONEY
• ANTIBACTERIAL
• ANTIINFLAMMATORY
• ELIMITE CREAM
• TREATMENT OF SCABIES
WHEN TO REFER TO SPECIALIST
• WHEN YOU DO NOT KNOW
• AFTER THE SECOND VISIT IF THERE IS NO RELIEF
• IF THE RASH IS ONE OF THE SEVEN DERM EMERGENCIES
• IF YOUR PATIENT ASKS FOR ONE
REFERENCES
• AMERICAN ACADEMY OF DERMATOLOGY. HTTPS://WWW.AAD.ORG/PRACTICE-TOOLS/QUALITYCARE/CLINICAL-GUIDELINES
• AWADALLA F, ET AL. (2008). DERMATOLOGIC DISEASE IN FAMILY MEDICINE. FAM MED, 40(7), 507-511.
• ELY JW, STONE MS. (2010). THE GENERALIZED RASH: PART II. DIAGNOSTIC APPROACH. AM FAM PHYSICIAN,
81(6), 735-739.
• LYONS, F. (2012). SOLVING SKIN RASHES IN PRIMARY CARE. HTTP://NURSE-PRACTITIONERS-AND-PHYSICIANASSISTANTS.ADVANCEWEB.COM/FEATURES/ARTICLES/SOLVING-SKIN-RASH-IN-PRIMARY-CARE.ASPX
• OWENS, J. N., SKELLEY, J. W., & KYLE, J. A. (2010). THE FUNGUS AMONG US: AN ANTIFUNGAL REVIEW. US
PHARMACIST, 35 (8), 44-56.
• SIMON, A., ET AL.(2009). MEDICAL HONEY FOR WOUND CARE—STILL THE ‘LATEST RESORT’?. EVIDENCE BASED
COMPLEMENTARY AND ALTERNATIVE MEDICINE, 6 (2), 165-173.