Dermatology Pearls for Inpatient Medicine · • Patient admitted to hospital for 4 plus weeks. •...

Dermatology Pearls for Inpatient Medicine

Dr Peter J Green MD FRCPC Professor, Division of Dermatology

Dalhousie University

Objectives

1. Review spectrum of cutaneous manifestations seen with inpatient population

2. Differentiate urgent and emergent presentations

3. Review therapeutic management of cutaneous diseases

Before we go on….

• If you say maculopapular…….

• Dermatologist thinks two things:

• You mean a viral or drug eruption

• You frontin'

The drug rash

The set up

• Patient admitted to hospital for 4 plus weeks.

• Develops red, itchy “rash” all over

• “No new soaps, ?laundry detergent on sheets”

• “ No new meds” ( better be sure……)

Key points: drug eruption• Common , delayed hypersensitivity

• Symmetric, blanching erythema that progresses over days, sparing mucous membranes

• Common triggers in hospital will be antibiotics , cardiac meds, seizure meds

• Will not be : warfarin, tylenol, constipation meds, sleeping pills, opiates, iron

• Danger signs: mucous membranes, painful, sick patient, blistering AND/OR specific LABS

Key points• Skin findings: new widespread, symmetric

eruption with recent drug exposure

• Always go back at least 3 weeks to look for new med exposure

• Make a time line to clarify drugs vs skin findings

Don’t….

X. Start benadryl just because someone has a drug eruption

X. Assume new skin findings in patient who started meds is a drug eruption

X. Re-challenge patients to meds they report as true allergy

Do….✓ Stop the suspected drug when possible

✓ Educate the patient about duration ( it gets more extensive before it gets better)

✓ Ask about previous exposures to same med

✓ Educate about re-exposure

✓ Know signs this is a serious drug eruption

Serious Drug Eruptions

• SJS/TEN

• Drug Hypersensitivity syndrome

• Acute generalized exanthematous pustulosis

SJS/TEN▪ SJS and TEN probably a spectrum of severe

blistering disease from drug exposure ▪ SJS/TEN - Widespread blisters predominant

on the trunk and face, with underlying erythema and one or more mucous membrane erosions

▪ SJS/TEN overlap BUT may be separated based on • 1. Clinical features/blistering pattern eg target vs

sheet like • 2. Percent of skin that is detached ie 10% vs 30%

When to suspect SJS/TEN▪ Patient looks and feels sick

▪ Widespread rash with dusky areas plus fever

▪ Skin is painful rather than pruritic

▪ Separation of skin/blistering

▪ Mucous membrane involvement

▪ Recent DANGER drug exposure

“Danger Drugs”▪ Allopurinol

▪ Anticonvulsants• Phenytoin, lamotrigine, carbamezapine,

phenobarbital

▪ Sulfa

▪ NSAIDs ( Oxicams)

▪ Antiretrovirals

Protocol for the Management of Drug Induced SJS/TEN in Adults Authors: Dr. A. Sutherland and Dr. L. Finlayson   Division of Clinical Dermatology and Cutaneous Science Dalhousie University

Admission – After Clinical Diagnosis of SJS/TEN ♦ Admit to ICU or IMCU (under medicine)

♦ Discontinue offending drug ♦ Monitor respiratory status for possible airway

intervention ♦ Establish IV access (through non-lesional skin if

possible) and begin fluid resuscitation with crystalloids (burn protocol)

• Goals – MAP > 65mmHg, CVP 8-12mmHg, urine output 0.5-1ml/kg/h

♦ Skin biopsy to confirm diagnosis (lesional skin) ♦ Reverse isolation in a heated environment with

strict contact precautions ♦ Monitor CBC, electrolytes and extended

electrolytes, liver function, creatinine, serum albumin, CRP/ESR, coagulation factors (transfuse as needed)

♦ Optimize pain management ♦ Calculate SCORTEN

Medical Therapy First Line (order both therapies together) ♦ Cyclosporine 3 mg/kg/day PO/NG divided twice daily for 7-14 days

(decrease to 1mg/kg/day divided BID if IV dosing) ☐ Monitor serum creatinine and blood pressure. Do baseline

creatinine and repeat before the end of treatment. ♦ And Etanercept 50mg subcut x 1

Second Line ♦ IVIG 1-2g/kg/day for 3 days (For NS dosing: http://novascotia.ca/dhw/

NSPBCP/IVIG-calculator.asp)

Additional Therapy ♦ Corticosteroids 1mg/kg/day x 4 weeks, tapered over 3-6 months

Protocol for the Management of Drug Induced SJS/TEN in Adults Authors: Dr. A. Sutherland and Dr. L. Finlayson   Division of Clinical Dermatology and Cutaneous Science Dalhousie University

Wound Care ♦ Burn care dressings by RN trained for burn care (if possible)

♦ Careful patient handling to reduce shear forces on skin ♦ Chlorhexidine/saline (1:5000 dilution) compresses x 20

mins to skin daily ♦ Non-adherent dressings (petrolatum coated such as

Jelonet) to denuded skin ♦ Avoid use of adhesive tapes ♦ Hydrous emollient application PRN once re-

epitheliaztion occurs ♦ Mucosal membrane care

♦ Chlorhexidine mouthwash QID ♦ Topical anesthetic or spray for buccal pain ♦ Petrolatum regularly to lips ♦ Foley catheter PRN

Protocol for the Management of Drug Induced SJS/TEN in Adults Authors: Dr. A. Sutherland and Dr. L. Finlayson   Division of Clinical Dermatology and Cutaneous Science Dalhousie University

Consultations to Consider ♦ Ophthalmology

o For consideration of amniotic membrane transplantation in those with moderate to severe ocular involvement and topical therapies such as lubricants

♦ Gynecology/Urology o If significant mucosal membrane

involvement

Other Supportive Measures ♦ DVT prophylaxis ♦ Consider pan-culturing and broad spectrum

antibiotics if indicated ♦ Nutrition supplementation through NG tube if

necessary (hypercaloric, high protein diet) ♦ Physical therapy and mobilization when able

Protocol for the Management of Drug Induced SJS/TEN in Adults Authors: Dr. A. Sutherland and Dr. L. Finlayson   Division of Clinical Dermatology and Cutaneous Science Dalhousie University

Drug Hypersensitivity Syndrome

• When to suspect

• Looks like a widespread drug eruption with erythema WITH FACIAL EDEMA

• Fever, lymphadenopathy , unwell patient

• Delayed onset after DANGER drug exposure ( 2-8 weeks)

• Atypical lymphocytosis, marked eosinophilia and/or other visceral involvement ( LIVER, KIDNEY, LUNG, HEART, THYROIDITIS)

DHS : Danger Drugs• Anticonvulsants

• Minocycline

• Allopurinoal

• Azothioprine

• Dapsone

• Sulpha

Drug Hypersensitivity Syndrome

• STOP offending drug

• Supportive therapies

• Investigate/monitor visceral involvement

• Consider prednisone 1mg/kg

• Lung/heart …. renal/liver less responsive

A case for you: Drug eruption or not…

The set up• 64 year old with DM admitted to hospital with

toe pain and suspected left limb cellulitis,

• Xray of toe shows non specific changes, no osteomyelitis

• IV antibiotics ( vanco )started with improvement of cellulitis

• 5 days after admission, nurses ask about cream to use for worsening and painful yeast infection

What is the hallmark clinical finding ?

Pustules

Acute Generalized Exanthematous Pustulosis

• Rapid appearance of fever, minute sterile pustules after antibiotic exposure (B-lactam , others)

• Often starts in intertriginous folds i.e. armpits, groin with more rapid spread

• Lasts for 1-2 weeks with progression towards desquamation ( peeling)

• Identify and D/C offending agent

AGEP: DIFF DX

• SJS/TEN

• DRESS

• Pustular psoriasis

• Staph scalded skin syndrome

And speaking of groins….

What about…

Inverse Psoriasis

One offs…test yourself

Case 1

New onset skin findings in someone admitted with

asthma flare..

I would describe as…

A. Oslers nodes and Janeway lesions

B. Target lesions

C. Hemorrhagic vesicles and bullae

D. Palpable purpura

I would diagnose…

A. Endocarditis

B. Erythema multiforme from mycoplasma pneumonia

C. Autoimmune bullous disease

D. Vasculitis

I would describe as…

A. Oslers nodes and Janeway lesions

B. Target lesions

C. Hemorrhagic vesicles and bullae

D. Palpable purpura

I would describe as…

A. Oslers nodes and Janeway lesions

B. Target lesions

C. Hemorrhagic vesicles and bullae

D. Palpable purpura

I would diagnose…

A. Endocarditis

B. Erythema multiforme from mycoplasma pneumonia

C. Autoimmune bullous disease

D. Vasculitis

I would diagnose…

A. Endocarditis

B. Erythema multiforme from mycoplasma pneumonia

C. Autoimmune bullous disease

D. Vasculitis

Vasculitis and skin• Small vessel

• Hypersensitivity ( drug, infection, CTD, meds)

• ANCA positive vasculitis

• Churg-Strauss, Granulomatous with polyangiitis, MPA

• Medium vessel

• Polyarteritis nodosa

Vasculitis• Clinical finding of palpable purpura confirms

vasculitis

• Laboratory investigations

• I start with : CBC, ANA, ANCA, cryoglobulins, hep B, hep C, BUN, Cr, urinalysis, IgG’s, C3, C4, ESR

Case 2

Chest rash 6 weeks duration in patient with

previous breast Ca

I would order…

A. Oral antiviral

B. Topical steroid

C. Cephalexin

D. Skin punch biopsy

Metastatic inflammatory breast carcinoma

Take home point: consider metastatic disease of breast with persistent, localized skin findings

24 year old with Downs syndrome admitted with pneumonia- care

giver mentions one year history of itch and rash

I would describe as…

A. Maculopapular

B. Dry and scaly

C. Generalized

D. Crusted

I would describe as…

A. Maculopapular

B. Dry and scaly

C. Generalized

D. Crusted

What is the hallmark clinical finding ?

Crusting

What does this finding confirm?

Crusted ( Norweigan scabies)

Crusted scabies• Severe infestation with 100’s of

mites

• Highly contagious

• Usual scabies treatment with Topical 5% permethrin is insufficient

• 6% salicylic acid and multiple treatments with 5% permethrin

• Oral Ivermectin is best but hard to get

• CONTACTS AND CONTAINMENT!!

Case 3

56 year old female admitted for 6 days for investigations of TIA

New skin changes, unresponsive to

Cephalexin over 48 hours

I would ask about…

A. Itch vs pain

B. Culture and sensitivities for fluid swab

C. Raynauds, photosensitivity , pleuritis/pericarditis, arthritis

D. Recent tick bite

I would ask about…

A. Itch vs pain

B. Culture and sensitivities for fluid swab

C. Raynauds, photosensitivity , pleuritis/pericarditis, arthritis

D. Recent tick bite

I would…

A. Switch to IV Cefazolin

B. Switch to Doxycycline 100mg BID 21 days

C. Treat with oral steroids

D. D/C antibiotics, supportive therapy

I would…

A. Switch to IV Cefazolin

B. Switch to Doxycycline 100mg BID 21 days

C. Treat with oral steroids

D. D/C antibiotics, supportive therapy

Allergic Contact Dermatitis

Allergic contact dermatitis• Numerous sources in topical preparations,

cosmetics, occupation etc

• eg Tea tree oil, vitamin E, Polysporin, adhesive, lidocaine, formaldehydes etc

• Range from eczematous to vesiculobullous

• Severe presentations resemble infections process

• Consider with well localized, ITCHY eruptions in a well patient who has failed to respond to antibiotics

Therapeutic hotline

Topical steroid• Potency determined by vasoconstriction assay

( NOT percentage of molecule)

• Absorption greatest on thinnest skin, least on thickest : eyelid/genitals>palms and soles

• Ointments ( vaseline) more potent than creams ( white)

• Dry and scaly vs oozing, exudative

What to use• PEDS:

• 1 % hydrocortisone cream or ointment

• ADULTS: FACE or FOLDS

• 1 % hydrocortisone cream or ointment

• ADULTS: BODY, EXTREMITIES

• Betamethasone valerate 0.1% OR triamcinolone acetonide 0.1% cream or ointment

Potency of steroids• Mild potency

• 1%HC

• Medium ( 100X)

• BMV/TRIAMCINOLONE/MOMETASONE

• High

• BETAMETHASONE DIPROPRIONATE/FLUOCINOLIDE

• Ultrahigh ( 600X)

• CLOBETASOL

How much to apply?

• More than the pharmacist will tell them….

• Fingertip unit = 0.5 gms

• Two palm surfaces

Steroids: tips• Fear of atrophy

• 1% HC will likely never cause atrophy , unless used under occlusion for prolonged period

• Choose base for AREA being treated e.g. ointments for hands/feet, lotions for scalp

• AVOID ‘shotgun’ mixes of steroids/antibiotics/antifungals

• eg: kenacomb/viaderm

Other complications of steroids

Perioral dermatitis• Acneiform facial eruption, perioral with sparing of

vermilion border

• Most common in children and adult females

• In adults, daily topical moisturizers implicated

• Topical steroids used to treat will create dependance, tolerance and escalation

• Treat with topical metronidazole/oral tetracyclines if moderate to severe

others

Questions