Serious Generalized Skin Disorders

1
Serious Generalized Skin Disorders

• Tintinalli 246

2
Erythema Multiforme

• Inflammatory disorder
• Ranges from
• Localized (EM minor)
• Multisystem (EM major, stevens-johnson syndrome)
• Commonly spring and fall

• Precipitants
• Mycoplasma
• Herpes
• Drugs
• Antibiotics
• Anticonvulsants
• Malignancies
• Etiology unknown

3
Erythema Multiforme

• Symptoms
• Malaise
• Fever
• Myalgia / Arthralgia
• Lesion
• Maculopapular
• Target

4
Erythema Multiforme

• Lesions first appear symmetrically on hands, feet
  and extensor surfaces
• Center of target lesion may evolve to become
  cyanotic or vesicle
• Lesions in successive crops healing over 5 7 days

5
Erythema Multiforme

• Vesiculobullous lesion on mucosal surfaces
• Ophthalmologic lesions
• EM Minor 10
• EM Major 75

6
Erythema Multiforme

• Treatment
• Outpatient to Hospitalization depending on
  severity
• Systemic steroids commonly used for symptomatic
  relief
• Antihistamines
• Viscous lidocaine rinses

7
Toxic epidermal necrolysis

• Explosive dermatosis with
• Tender erythema
• Bullae formation
• Subsequent exfoliation
• Many consider this the same as SJS variant of EM

• Etiologies
• Medications
• Sulfa
• Penicillin
• Anticonvulsants
• Oxicam nonsteroidals
• Malignancy
• HIV
• Often unknown

8
Toxic epidermal necrolysis

• Symptoms
• Prodrome 1 2 weeks
• Malaise
• Anorexia
• Arthralgias
• Fever
• URI
• Skin tenderness

9
Toxic epidermal necrolysis

• Skin signs
• Warm erythema
• Initially involving the eyes, nose, mouth and
  genitalia, and then becoming generalized.
• Erythematous areas become confluent quickly
• Flaccid bullae appear
• Nikolsky sign
• Epidermis denudes in sheets

10
Toxic epidermal necrolysis

• Treatment
• Hospitalization
• Burn unit optimal
• Fluids
• Antibiotic prophylaxis??

11
Exfoliative Dermatitis

• Cutaneous reaction where most or all of the skin
  is involved with a scaly erythematous dermatitis
• Causes
• Drug or chemical exposure
• Underlying systemic or cutaneous disease

• Symptoms
• Abrupt or slow onset
• May be chronic
• Generalized erythma
• Warmth, scaling, flaking
• Pruritus
• Usually no tenderness

12
Exfoliative Dermatitis

• Treatment
• Dermatology consult
• Admission
• Correct hypothermia
• Correct hypovolemia
• Steroids often used

13
Toxic Infectious Erythemas

• Toxic shock syndrome
• Nonpuritic, blanching macular erythroderma
• Diffuse
• Erythroderma resolves over 5 days.
• Fine desquamation of hands and feet from 5 to 14
  days

14
Toxic Infectious Erythemas

• Streptococcal toxic shock
• Involves multiple organs
• Fever, hypotension, skin findings
• Erythema
• Edema
• bullae
• Cause group A Strep (S. pyogenes)

15
Toxic Infectious Erythemas

• Staphylococcal scalded skin syndrome
• Clinically in apparent infection common
• Conjunctiva
• Nasopharynx etc
• From exotoxin
• Acantholysis
• Intraepidermal cleavage
• Mostly infants / children

16
Toxic Infectious Erythemas

• Phases
• 1. Initial
• Tender erythroderma
• Sandpaper texture
• Mucous membranes spared
• 2. Exfoliative
• Usually day 2
• Skin wrinkles, peels
• Nikolsky sign
• Large bullae form
• 3. desquamation
• Days 3-5
• Involved skin desquamates

17
Disseminated Viral Infections

• Infectious exanthems
• Adenovirus
• CMV
• Coxsackie
• Echovirus
• EBV
• Hepatitis B
• HHV 6
• RSV
• Rotovirus
• Etc.

18
Disseminated Viral Infections

• Herpes zoster
• Cluster of vesicles on an erythematous base

Stromal keratitis
19
Disseminated Viral Infections

• Herpes simplex
• HSV 1 / 2 usually involve localized skin or
  mucous membranes
• Vesicular rash
• 2 3 mm, umbilicated
• Ulcerate and crust

20
Disseminated Gonococcal Infection

• 2 of genital GC
• Symptoms
• Fever
• Arthralgia
• Multiple papular, vesicular, or pustular lesions
• Extensor surfaces
• Small lesion develops to necrotic center

21
Rocky Mountain Spotted Fever

• Multisystem illness
• Rickettsia rickettsii
• Tick vector
• Symptoms
• Constitutional 1 week
• Rash 4 days later
• 1st wrist / ankles then palms and soles and moves
  centrally

22
Meningococcemia

• Neisseria meningitidis
• Acute entity
• Pharyngitis
• Meningitis
• Bacteremia
• Symptoms
• Severe headache, stiff neck, fever, AMS, N/V,
  myalgia, rash
• Petechia, urticaria, hemorrhagic vesicles,
  macules
• Extremities and trunk
• Other areas possible

23
Purpura Fulminans

• Vascular disorder
• Fever, shock, multiorgan failure, rapid
  development of skin necrosis
• Eccymosis, hemorrhagic bullae, epidermal necrosis
• Causes
• Protein C or S deficiency
• DIC

24
Bullous Diseases

• Pemphigus vulgaris
• Generalized, mucocutaneous, autoimmune,
  blistering erruption
• Vessicles or bullae from 1 3 cm and are clear
  and tense, and break.
• Affect head, neck trunk and mucous membranes

25
Bullous Diseases

• Bullous pemphigoid
• Generalized mucocutaneous blistering disease of
  the elderly.
• Tense blisters up to 10 cm
• Ulceration with tissue loss follows