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Dermatology Review

2020 EMRAM In-Service

Julie Parks Bortel MD, FACEP

Lecture

Overview

◼ Terminology Review

◼ Describe the key features and a typical

dermatologic presentation for each condition

◼ Case review of common and important rashes

Approach to rashes◼ Determine how the rash started and evolved

◼ Note the distribution, pattern, and configuration

mucous membrane involvement

palm/sole involvement

◼ Is it pruritic or painful

◼ Any prodromal symptoms

Terminology

◼ Excoriation – linear

erosion

◼ Fissure - linear cracks

in skin surface

Terminology

◼ Macular –Flat and

<1cm

◼ Patch – Flat and

>1cm

Terminology

◼ Papule – Raised

<1cm

◼ Plaque – Raised

>1cm

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Terminology

◼ Vesicle - Blister <1cm ◼ Bullae - Blister >1cm

Terminology

◼ Nodule – Dermal or

subcutaneous lesion

<2 cm

◼ Tumor – Dermal or

subcutaneous lesion

>2cm

Terminology

◼ Pustule – vesicle with

purulent fluid

Scale - visible layers of

stratum corneum

getting shed from the

skin

Terminology

◼ Erosion – Loss of part

or all of the epidermis

◼ Ulcer – Dermis or

deeper

Terminology

◼ Telangiectasia - small, blanching surface

capillaries

Terminology

◼ Purpura – non-blanching purple discoloration > 2mm

◼ Petechiae -- non-blanching purple spots < 2mm in diameter

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Terminology

◼ Wheal -- transient, edematous papule or plaque with

peripheral erythema

Dermatitis

Rash #1

◼ A 9 month old boy

with a history of

asthma is brought in

by his mother for an

itchy red rash

Dermatitis aka Eczema

◼ Inflammation of the epidermis

◼ Group of skin conditions that includes:

Atopic dermatitis

Allergic contact dermatitis

Irritant contact dermatitis

Stasis dermatitis

◼ Exact cause is often unknown

Atopic Dermatitis

◼ A type of dermatitis with a hereditary

component

◼ Atopic triad – asthma, eczema, allergies

◼ Common in developing countries

◼ Variety of symptoms – erythema, edema,

vesiculation, flaking, weeping, & itching

◼ Treatment aimed at decreasing inflammation

Atopic Dermatitis

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Atopic Dermatitis

◼ Diagnosis is made by having three or

more major features and three or more

minor features

Atopic Dermatitis

◼ Major Features

Pruritis

Typical morphology and distribution

◼ Flexural lichenification in adults

◼ Facial and extensor involvement in kids

Dermatitis – chronic or relapsing

Personal or Family History of atopy

Minor Features

◼ Cataracts

◼ Chelitis

◼ Recurrent conjunctivitis

◼ Facial pallor/erythema

◼ Food intolerance

◼ Hand dermatitis

◼ Ichthyosis

◼ Elevated IgE

◼ White dermographism

◼ Wool intolerance

◼ Xerosis

◼ Infections – Staph, herpes

Atopic Dermatitis

◼ NOT caused by a true allergic reaction

◼ Results from defective cell mediated

immunity reactions brought on by

environmental stress

◼ May have a primary T-cell defect

Atopic Dermatitis

◼ Highest incidence in children

◼ Two Subgroups

1. Patients with asthma and enhanced IgEproducing potential

2. Patients without asthma or enhanced IgE

◼ More than 50% of kids with atopic dermatitis develop asthma by the age of 13

Atopic Dermatitis

◼ Clinical Features

Starts with itching

The scratching creates the patterns of the

disease

Initially there is acute inflammation followed

by slow resolution and replacement with dry,

scaly skin (Ichthyosis/xerosis)

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Atopic Dermatitis

◼ AcuteBright red swollen

plaques

Often linear vesicles

Intense itching

◼ SubacuteVarious patterns of

erythema and scale

Mild to moderate itching

Indistinct borders

◼ Chronic Inflamed area is

thickened

Parallel skin markings

Commonly involved areas are easy to reach

3 Phases of Atopic Dermatitis

◼ Infantile Phase (2mo-2yrs)

Affects cheeks, perioral area, scalp, ears,

trunk (spares diaper area), tops of feet, and

elbows

Lesions often exudative

Atopic Dermatitis Phases

◼ Childhood Phase (2-12 yrs)

Flexural involvement

Scratching and chronicity leads to

lichenification

Atopic Dermatitis Phases

◼ Adult Phase (12-adult)

Flexural involvement is common

Hand dermatitis may be only manifestation

Upper lid dermatitis is also common

Associated findings include dry skin,

ichthyosis vulgaris, and keratosis pilaris

Atopic Dermatitis Complications

◼ Skin lesions frequently colonized with staph and secondary infections are common

◼ Increased susceptibility to viral infections

◼ Inflammation can lead to pigmentation changes

◼ In children with moderate-severe disease may also have emotional/behavioral problems

Atopic Dermatitis Treatment

◼ Topical Steroids

◼ Oral Antibiotics for secondary infection

◼ Burrow’s Solution

◼ Lubricant to restore skin barrier

◼ Eliminate aggravating factors

◼ Control Pruritis

◼ Short course of oral steroids if needed

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Rash #2◼ 35 y.o. male was outside yesterday

mowing his lawn and trimming bushes

now presents to the ER for an intensely

itchy rash.

Allergic Contact Dermatitis

◼ Delayed hypersensitivity reaction

◼ It affects a limited number of people after

they have been exposed to an antigenic

substance

◼ Reactions develop acutely in 6-72 hours

Allergic Contact Dermatitis

◼ Examples

Poison Ivy/oak/sumac

Glue

Insecticides

Acrylics

Latex

Nickel

Neomycin

Poison Ivy/Oak/Sumac

◼ Requires prior sensitization

◼ Caused by the antigen Urushiol

◼ Rash occurs between 6-72 hours after exposure

◼ Lasts 2 days – 3 weeks

◼ Rupturing the vesicles does not spread the rash

◼ Highly characteristic linear lesions

Poison Ivy Poison Oak

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Poison Sumac Treatment

◼ Mild

Calamine lotion

Benadryl

Topical Steroid

◼ Moderate – Severe

Aveeno bath

Oral Benadryl

Systemic steroids

Rash #3◼ 40 y.o. construction worker who has been

on a job repaving I-75 presents with an

itchy rash. He reports that it improved

over vacation but now seems worse

Irritant Contact Dermatitis

◼ Caused by exposure to environmental substances

◼ Level of irritation is related to duration of exposure and concentration of substance

◼ Gradual onset

◼ Borders correspond to the pattern of the offending agent and often assist in the diagnosis

Contact Dermatitis Irritant Contact Dermatits

◼ Shampoos/soaps

◼ Fuels/lubricants/cement

◼ Pineapple juice

◼ Alcohols, alkalies, grease

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Rash #4◼ A mom presents to the ER with her 4

month old for a rash. She reports that she

noticed it while changing the diaper and

the child was screaming while being wiped

so she came in for evaluation.

Diaper Dermatitis

◼ Candida – beefy red plaques with well

defined edges

◼ Irritant/Contact

Dyshidrotic Dermatitis

◼ Itchy 1-2mm blisters on the palms of the

hands or soles of the feet

◼ Take ~3wks to heal

◼ Often recur

◼ Cause is unknown

Rash #5◼ A 77y.o. male with a history of HTN, DM,

CAD, & CHF comes in for a rash that has

been progressively more noticeable for the

last 6 years but it was on his mind and he

couldn’t sleep so he came in for evaluation

at 3am.

Stasis Dermatitis

◼ Skin changes in the

legs that occur from

insufficient venous

return leading blood

to pool

◼ Pooling blood

increases pressure in

the capillaries and

fluid leaks into the

tissue

Rash #6

◼ 30 y.o. female presents for a bump on the

back of her neck which started to leak a

cheesy material prompting her

presentation to the E.R.

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Epidermal Inclusion Cyst

◼ Solitary lesion that usually occurs on the

face/neck/scalp/upper trunk

◼ May occasionally become inflamed,

tender, and have foul-smelling drainage

◼ Mobile dermal to subcutaneous nodule

Epidermal Inclusion Cyst

Epidermal Inclusion Cyst

◼ Treatment – non-emergent unless

inflamed

◼ If inflamed I&D may be helpful

◼ May inject steroids

◼ Keflex if indicated

◼ PCP can excise after inflammation

improves

Rash #7

◼ 25 y.o. female presents with a red scaly

prominent itchy rash on the scalp

Psoriasis

◼ Abnormal immune reaction to skin cells

◼ Causes acceleration of the growth cycle of cells

◼ Salmon colored plaques and papules that are well-circumscribed

◼ Most commonly on extensor surfaces such as the knees and elbows

◼ Treatment: topical, phototherapy, & immune modulators

Psoriasis Subtypes

◼ Plaque – red patches with white scales

◼ Guttate - small droplike papules

◼ Pustular – presents with small non-

infectious pus filled blisters. Often on

palms and soles

◼ Inverse – Red patches in skin folds

◼ Erythroderma – near to total body

psoriasis

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Psoriasis Psoriasis

Rash #8

◼ Mom presents to the

ER with her 4 month

old infant complaining

of a greasy yellow

rash on her baby’s

head

Seborrheic Dermatitis

◼ Common chronic inflammatory dermatitis

◼ Characteristic distribution

Infants – vertex of scalp, diaper area, skin

folds

Adults – scalp, eyebrows, nasolabial folds,

paranasal skin, around the ears, presternal

skin and upper back

Seborrheic Dermatitis

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Seborrheic Dermatitis Treatment

◼ Shampoos to decrease dandruff

◼ Low dose steroid creams – when

necessary

Cradle Cap

◼ neonatal seborrheic dermatitis – greasy, yellow rash

◼ Uncertain of cause ? Related to eczema

Fungal

Overactive sebaceous glands

◼ Treatment Many home remedies – Vegetable oil, Baking soda, herbal

washes

Shampoo, Tar, Steroids, Ketoconazole

Maculopapular

Rashes

Rash #9

◼ A 22 y.o. male presents to the EC complaining

of an intensley painful red rash. Yesterday he

was out on a boat all day partying at

jobbienooner.

Sunburn◼ Acute inflammatory reaction in

response to UV A & B rays

◼ Erythema peaks at 12-24 hours

◼ In severe cases, can lead to 2nd

degree burns

◼ Are there any photosensitizing medications?

◼ Treatment

Cool soaks or OTC cooling agents

Anti-prostaglandins – ASA or NSAIDS

Steroids

Rehydrate and treat at burn center

Rash #10

◼ A 7 y.o. male presents to the ER for an

itchy rash after playing outside on a hot

humid day

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Heat Rash

◼ Pruritic erythematous vesicles and papules

◼ Accompanied by burning, “prickly” sensation

◼ Common in kids due to underdeveloped sweat

glands

Rash #11

◼ A 10-year-old boy had a seizure & was

started on oral phenytoin. 3 weeks later he

developed conjunctivitis & painful oral

sores and was brought to the ER for

evaluation

Erythema multiforme

◼ Acute inflammatory mucocutaneous skin disease

◼ Pathogenesis – unknown likely hypersensitivity reaction to infection such as HSV or

mycoplasma, connective tissue disorders, malignancy, drugs (antibiotics and anticonvulsants), pregnancy

50% are idiopathic

◼ Wide clinical spectrum EM minor

EM major

Stevens-Johnson Syndrome

TEN (Toxic epidermal necrolysis)

Erythema multiforme

◼ Clinical

Malaise, arthralgias, myalgias, fever, diffuse

pruritis, generalized burning sensation may

precede rash

Skin lesions

◼ Erythematous papules

◼ 24-48 hrs: maculopapules, target lesions with

dusky violaceious center, urticarial plaques,

vesicles, bullae, and mucosal erosions

◼ Palms and soles are characteristic

◼ Ocular involvement particularly in SJS, TEN

Spectrum of Erythema Multiforme

Course Cutaneuos

involvement

Mucosal

involvement

Duration Prognosis

EM minor Self-limited Target lesions, blisters

< 10% BSA, (-)

Nikolsky

Absent or limited

to 1 site

1-3

weeks

Good, may

be episodic

EM major Self-limiited Target lesions, blisters

< 10% BSA, (-)

Nikolsky

Involvement

almost exclusively

oral

1-6

weeks

May be

episodic

SJS Progressive

severe

systemic

illness

Widespread bullae,

predominantly torso,

epidermal detachment

< 10%, (+) Nikolsky

2 or more mucous

membrane

involved

extensively

2-6

weeks

10%

mortality

TEN Prodrome

then

mucosal,

followed by

systemic

illness

Widespread lesions,

predominantly torso,

epidermal detachment

> 30%, (+) Nikolsky

1 or more mucous

membrane

involved

extensively

2-6

weeks

30%

mortality

Erythema Multiforme Treatment

◼ EM minor and major – may be treated as

outpatient with analgesics, oral

care/rinses, acyclovir if caused by HSV

Widespread outbreaks may respond to

steroids

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Stevens-Johnson Syndrome

◼ Symmetric severe vesicobullous eruption

◼ Affects at least 2 mucous membranes

◼ 5-10% mortality rate

Stevens-Johnson Syndrome

◼ History of Illness

1-3 week prodrome of fever, malaise,

mayalgias

Usually in children and young adults

Commonly caused by HSV, mycoplasma or

drugs

Stevens Johnson Syndrome

◼ Physical Findings

Rash lesions vary from erythematous

papules, vesicles, to target lesions

Bullae erode resulting in gray-yellow fibrinous

exudates with thick hemorrhagic crusts

Ocular changes – conjunctivitis, bullae,

corneal ulcers, and uveitis

Stevens Johnson Syndrome

◼ Physical Findings

Mostly on extremities, but may spread to face

and trunk

Fever – 3%

Pneumonitis – 23%

Bronchitis – 6%

Stevens Johnson Treatment

◼ Supportive care

◼ Ophthalmology consult

◼ Self limited disease

◼ 10% mortality for extensive disease

Toxic Epidermal Necrolysis

◼ Exfoliative disease that affects 30-100% of

BSA

◼ High mortality

◼ 80% are secondary to drugs

Dilantin, barbs, tegretol, sulfa, PCN, &

NSAIDS

Other causes include vaccines, TB, & viruses

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Toxic Epidermal Necrolysis

◼ Skin eruptions are often confluent with

target lesions or bullae

◼ Widespread full thickness necrolysis of

the epidermis

◼ Involve mucous membranes

◼ Positive Nikolsy sign

Toxic Epidermal Necrolysis

◼ Symptoms

Fever, malaise, arthralgias,

Leukopenia, thrombocytopenia, and anemia

30% have upper airway involvement

Hypovolemia

Wound infections & sepsis

Stevens-Johnson Syndrome

10-year-old boy had a seizure & started on oral

phenytoin. 3 weeks later he developed conjunctivitis

& oral mucositis. The picture is 48 hours later.

TEN

SJS & TEN Treatment

◼ SJS and TEN –

Stop the offending drug/treat underlying

illness

May require supportive, ICU care

Treat as burn patient

Remember to check eyes and consult

ophthalmology

Parkland Formula

◼ Wt 100kg

◼ BSA 25%

◼ Fluids = BSA x wt(kg) x 4ml/kg

◼ Answer 10 liter fluid deficit

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Rash #12

◼ 23 y.o. female

presents with a

painless rash. She

is otherwise healthy

but mentioned that

she had a cold a

couple weeks ago.

Pityriasis Rosea

◼ Oval shaped salmon colored papules or plaques on the trunk & proximal extremities with a red halo

◼ Herald patch and Christmas tree pattern

◼ Children and young adults

◼ Resolves in weeks to months

Rash #13

26 y.o. female with a

history of sarcoid

presents with a

history of a week of

myalgias and a

fever. Today noticed

a painful rash on her

bilateral shins

Erythema Nodosum

◼ Inflammatory/immunologic reaction

◼ Women 15-30 y.o.

◼ Deep painful nodules on the lower extremities

◼ Bilateral but not symmetric

◼ Tender to palpation

◼ Preceded by fever, malaise, & arthralgias

◼ Causes: Infection, Drugs, Cancers, Sarcoid/IBD, Pregnancy

◼ Self limited if the cause can be eliminated

Rash #14

7 y.o. male presents for

severe abdominal pain.

Parents say that he had

jaundice at birth but no

other health problems. He is

fully immunized and takes

no medications. A week

ago he had a runny nose

but they otherwise deny any

constitutional symptoms.

On exam you completely

undress the boy and see

this rash

Henoch-Schonlein Purpura

◼ Systemic vasculitis that causes palpable purpura

◼ Usually follows an upper respiratory infection

◼ 90% of cases occur in children <10 y.o.

◼ Triad – purpura, joint pain, and abdominal pain

◼ Purpura is usually located on the legs and buttocks

◼ 40% of cases involve the kidneys Hematuria, proteinuria, and some will have nephrotic

syndrome

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HSP

Viral Rashes

Rash #15

◼ A 35 y.o. female presents with a painful

rash on her lip. She is otherwise healthy

but reports being under a lot of stress with

her work and family

Herpes Simplex

◼ HSV I – associated with oral lesions

◼ HSV II – associated with genital lesions

◼ Treatment – Oral antiviral agents are most

effective within 48 hours of outbreak

Herpes Simplex Rash #16

◼ A 38 y.o. male

presents with

severe RLQ pain

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Shingles/Herpes Zoster

- Reactivation of latent varicella zoster

- 10-20% Incidence

- Triggers – age, immunosuppression, fatigue, stress- Patient’s with Hodgkin’s disease are uniquely susceptible

- May have constitutional symptoms of fever, HA, & malaise prior to the rash

Herpes Zoster

Shingles- Starts as pain and paresthesias in a dermatomal

distribution 3-5 days prior to rash

- Herpetiform clusters of vesicles on an erythematous edematous base

- Hutchinson’s sign – lesions on the tip of the nose can signal eye involvement

- Ramsay Hunt Syndrome – Lesions in the ear canal associated with facial palsy

- Treatment – analgesics and antivirals

Shingles Ophthalmic Zoster

◼ 10-20% of all zoster cases

◼ 72% develop ocular complications

◼ Hutchinson’s sign

Zoster Diagnosis and Treatment

◼ Tzank smear shows multinucleated giant

cells

◼ Oral antivirals – most effective in the first

48hours

◼ Sympathetic blocks with bupivicaine may

help the pain of acute zoster

Postherpetic Neuralgia

◼ Incidence and duration of pain increases

with age

◼ Patients over 60 may benefit from Elavil or

Neurontin

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Rash #17◼ 4 y.o. female is brought

into the ER for a fever

and rash. Mom reports

that the child has had a

cough, runny nose, and

increasing fever over the

last 3 days. This morning

the child woke up with a

rash and mom became

concerned.

◼ PMHx: NSVD, no health

problems

◼ Rx: none

Social Hx: lives at home

with 5y.o. brother and pet

dog

◼ Immunizations: None

◼ Vitals: T 39, RR 20, HR

120

On exam you see

Measles/Rubeola

◼ Erythematous maculopapular to confluent rash

◼ Starts on the forehead/behind ears and spreads downward to the face, trunk, and extremities (includes the palms and soles)

◼ Paramyxovirus

◼ Infectious from 3 days prior to rash to 5 days after

◼ Symptoms: Gradually increasing fever

4 C’s - “barking” cough, coryza, conjunctivitis, Koplick spots

◼ white papules on an erythematous base on buccal mucosa

Rash #18

◼ A 5 y.o. boy presents to the ER for a rash

on his face and body. Mom reports that he

had a mild fever and didn’t feel well over

the weekend and then today (2 days later)

he woke up with a rash on his face and

now mom says it has spread further.

PMHx: Recurrent OM

Vaccines: Mom gave most of them but got nervous about autism so

she skipped “a few”

Exam: T 37.4 RR18 HR 105

Rubella/German Measles

◼ Pink/Red maculopapular rash

◼ Starts on the face and rapidly spreads down

◼ Fades by the 3rd day

◼ Rubivirus

◼ Complications – arthritis, encephalitis, thrombocytopenia, congenital rubella in first trimester exposure

◼ Symptoms Prodrome of fever and malaise

Forchheimer’s sign – pinpoint petechiae on the soft palate

Lymphadenopathy

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Rash #19

◼ 3 y.o. female brought to the EC for a high

fever for 4 days that persists in spite of

Tylenol and Motrin

◼ The child is otherwise healthy, immunized,

and behaving normally

ExamVitals:

T 39.6 RR 18 HR 131

Roseola

◼ High fever for 3-4 days in a well-appearing

child followed by rash

◼ Blanching rose colored macular to

maculopapular rash that starts on the

trunk and spreads outward

◼ Human herpes virus 6 & 7

◼ Usually in kids 6 months to 3 years

Rash #20

◼ 6 y.o. male presents with a mild fever and

malaise and a rash on his cheeks.

Erythema Infectiosum/

Fifth’s Disease

◼ Bright red malar rash - “slapped cheek” -

followed in 2 days by an erythematous

maculopapular rash on the trunk and limbs

◼ Central fading leads to a lacy pattern

◼ Parvovirus B19

◼ No longer contagious once rash appears

◼ Can cause hydrops fetalis in pregnancy or

aplastic crisis in hemolytic anemias

Fifth’s Disease

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Rash #21

◼ 4 y.o. male presents with fever, headache,

malaise over the last 3 days. Mom noticed

a rash on the face that is now spreading

◼ The child now has a poor appetite and is

intensely itchy

Exam

◼ T 38.2 RR 20 HR120

Varicella

◼ Vesicular rash that starts on the face and

spreads to the trunk (includes mucus

membranes) and extremities (palms/soles

spared)

◼ Vesicles rapidly evolve into pustules which

umbilicate and crust

“dew drop on a rose petal”

Rash #22

◼ A 15 y.o. wrestler

presents for a

rash on his feet

Warts

◼ Viral infection caused by HPV

◼ Cauliflower-like appearance

◼ Transmission occurs by direct contact and

autoinocculation

Wart Treatment

◼ Usually disappear after several months but

can last years and/or recur

◼ May resolve spontaneously

◼ Salicylic acid

◼ Liquid nitrogen cryotherapy

◼ Electrocautery

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Rash #23

◼ 10 y.o. female brought

to the ER by her mom

who is frustrated that

she has had a rash for

4 months

◼ Occasionally itchy but

no other symptoms

◼ She is fully vaccinated

and otherwise healthy

Molluscum Contagiosum

◼ A viral infection of the skin and occasionally mucous membranes

◼ Most commonly on the trunk/arms/legs

◼ DNA poxvirus

◼ Spread from person to person via direct contact

◼ Most common in children one – 11 y.o.

◼ Contagious until the lesions are gone

Molluscum Contagiosum

◼ Flesh-colored, dome-shaped, and pearly appearance

◼ 1-5mm diameter with a dimpled center

◼ Painless but may be pruritic

◼ Most lesions clear in 6-12 months and average outbreak is 8-18 months

◼ Resolves without scarring

◼ Extremely contagious

Molluscum Contagiousum

Molluscum Contagiosum

Treatment

◼ Usually self-limiting

◼ Mild Cases – OTC Salicylic acid or retinoin

cream

Other Rashes

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Rash #24

◼ 72 y.o. female presents

for a painful rash on her

cheek. She reports 2

days of a fever, poor

appetite, and malaise

◼ T 38.7 RR 18 HR 117

98% RA

PMHx: DM, HTN

Erysipelas

◼ Painful, shiny, erythematous plaques with raised

and sharply demarcated borders

◼ Form of cellulitis and favors extremities

◼ Group A strep

◼ Usually occurs in young kids and the elderly

◼ Associated with high fever, chills, & anorexia

◼ Treatment: PCN, E-mycin, or Clindamycin

Rash #25

◼ 25 y.o. female presents for a painful rash

on her finger and joint pain

◼ PMHx: Asthma, genital warts

◼ Social Hx: +tob, social Etoh, works at a

gentleman’s club as a dancer

Disseminated gonococcal infection

◼ Clinical

Fever

Classic triad

◼ 1. migratory arthralgias

◼ 2. tenosynovitis (usually fingers)

◼ 3. dermatitis

multiple papular, vesicular, or pustular skin lesions (usually

initially small papules or macules that evolve to pustules),

often on extremities

*6 million new gonorrhea infections yearly in US. 3% cases may become disseminated.

Up to 75% of those diagnosed with disseminated disease are females in late pregnancy,

immediate post-partum, or within 1 week of onset of menses.

Disseminated gonococcal infection

◼ Diagnosis

Gram stain or culture of

blood or lesions reveals

Neisseria gonorrhoeae

◼ Treatment

Begin parenteral treatment

with ceftriaxone –

quinolones should be

avoided in certain regions

due to resistance

Rash #26

◼ 28y.o. male presents to

an urgent care after he

noticed a rash on his leg

◼ PMHx: None

◼ Social Hx: Social Etoh, no

tobacco, worked as a

camp counselor over the

summer and returned to

college 2 weeks ago

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Lyme Disease

◼ Tick born disease

◼ Early localized disease has a circular outwardly

expanding rash – erythema chronicum migrans

– at the site of the tick bite

◼ Occurs 3-30 days after bite

◼ Associated with flu-like symptoms

◼ Treatment – Doxycycline or Amoxicillin for 10-28

days

Rash #27

◼ 8 y.o. male presents to the ER for fever,

malaise, headache, and nausea. Mom

reports that he hasn’t felt well since they

returned from a hiking trip in Virginia a

week ago

Rocky Mountain Spotted Fever

◼ Epidemiology

Rickettsia rickettsii

transmitted to humans by

wood ticks and dog ticks

All US states except AK, HI

90% patients infected April

to Sept

Half of cases from S.

Atlantic states

>60% history of tick bite

Peak age 5 to 9 years old

Rocky Mountain Spotted Fever

◼ Initial symptoms 5-7 days after inoculation Fever – only universal sx

Nausea, vomiting

Frontal headache

Myalgias

Anorexia

Light macules on distal extremities/palmar surfaces

◼ Later symptoms Petechial rash spread

towards trunk

Abdominal pain

Joint pain

◼ Extreme gastrocnemius

tenderness may be a clue

Diarrhea

CNS, renal, and respiratory

failure

Rocky Mountain Spotted Fever

◼ Diagnosis is clinical 1. Fever 2. HA 3. Rash

◼ Lab findings Low sodium and platelets

Elevated liver enzymes

◼ Treatment Supportive

Doxycycline or chloramphenicol – begin prior to lab confirmation of diagnosis!◼ High mortality rate due to late/missed diagnosis

Rash #28

◼ A 22 y.o. male presents complaining of an

intensely itchy rash on his hands that

seems worse at night.

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Scabies Scabies

◼ Caused by the mite sarcoptes scabiei

◼ Burrows under the skin, usually in the

creases

◼ Pruritis intensifies at night

◼ Treatment – Permethrin, Ivermectin

◼ Reinfection is common

Rash #29

◼ A 2 y.o. girl is brought in by her mother for

a rash on her mouth

Impetigo

◼ Bacterial skin infection

◼ Children < 6 y.o.

◼ Highly contagious

◼ Impetigo Contagiosa

Most common, usually occurs on the face & extremities

S. aureus, Group A Strep

Small pustules/vesicles with erythematous margins that rupture and cause thick honey colored crusts

Treatment – Antiobiotics - Oral or topical (Mupirocin2%) depending on severity and Good hygiene

Impetigo

◼ Bullous Impetigo

Usually seen in neonates

Lesions are usually periumbilical, perineal, or

on extremities in older kids

Flaccid bullae (1-3 cm) that rupture and leave

shiny, round erythematous erosions with

peeling edges (“coin lesions”)

Impetigo

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Rash #30

◼ A 4 y.o. male is brought to the ER by his

mother for a fever, lethargy, and vomiting.

On exam you see the following rash:

Meningococcemia

◼ Epidemiology

Incidence higher in spring and fall

Highest incidence in children < 5

◼ Pathophysiology

N. meningitidis enters the body via the nasopharynx

◼ Asymptomatic carrier: remains in nasopharynx

◼ Mild URI

◼ Severe disease

Bacteremia, sepsis, meningitis

Meningococcemia

◼ Clinical – wide spectrum

Classic – fever and petechiae or purpura present 60%

cases

Other symptoms

◼ n/v/d, seizure, lethargy, cough, rhinorrhea

Danger -- extremely rapid course to sepsis, DIC

10% develop fulminant meningococcemia

(Waterhouse-Friederichson syndrome)

Purpura fulminans

◼ vascular disorder characterized by fever,

mulitorgan failure and hemorrhagic skin necrosis

Rash #31

◼ A 70 y.o. man

presents for

bleeding from

a wound on

his back

◼ Skin caSkin Cancers

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Basal Cell Carcinoma

-Most common skin cancer

-Usually caused by sun exposure but some

have a genetic component

-Low risk of metastasis

-Usually occur after 40 y.o.

Basal Cell Carcinoma

◼ Appearances

Typical

◼ Shiny, pearly skin nodule

Superficial

◼ A red patch similar to eczema

Infiltrative

◼ Skin thickening or scar tissue appearance

Basal Cell Carcinoma Basal Cell Carcinoma

◼ Rarely life threatening

◼ Metastasis is rare

◼ 96% five year survival rate after excision

Basal Cell Variants

◼ Nodular

most common

Pearly, white dome-shaped lesion with

telangiectasias. Often has a central

ulceration

Basal Cell Variants

◼ Pigmented

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Basal Cell Variants

◼ Superficial

Basal Cell Variants

◼ Micronodular

Basal Cell Variants

◼ Morpheaform

Most subtle

Least common

Pale white to yellow

Basal Cell Nevus Syndrome

◼ Autosomal dominant condition

◼ Involves defects in the skin, nervous

system, eyes, bones, & endocrine system

◼ Atypical facial appearance

◼ 90% develop basal cell cancers

Basal Cell Nevus Syndrome

◼ Basal_cell_nevus_sye

Squamous Cell Carcinoma

◼ Usually occurs in 50-70

year olds

◼ 2nd most common skin

cancer (20%)

◼ ~ 90% occur in sun

exposed areas

◼ Risk of metastasis

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Squamous Cell Skin Cancer

Presentation

◼ Slow Growing asymptomatic lesion

◼ Ulcer or reddish skin plaque to hard

plaque/papule

◼ May start as actinic keratosis

◼ May have intermittent bleeding

◼ Risk of metastasis is higher in lip or scar

lesions

Squamous Cell Carcinoma

Prognosis

◼ Excellent long term prognosis after

surgical excision

◼ Topical chemotherapy and radiation may

also be used

◼ ~4% at risk of metastasis

Higher in immune compromised patients

10-20% risk in lip or ear lesions

Malignant Melanoma

◼ 8th most common cancer in the US

◼ Caused by UV exposure and/or genetics

◼ 25% develop from moles

◼ Diagnosed with biopsy

Malignant Melanoma

◼ Risk Factors

Atypical Nevi – 25-30% develop from moles

Fair skin

UV exposure

Family History

Immune deficiency

Congenital - xeroderma pigmentosum

Malignant Melanoma

Presentation

◼ Change in Mole Appearance

Increase Size

Change in Shape

Change in Color

◼ Early Symptoms are itching, pain,

bleeding, and ulceration

◼ 70% develop de novo

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Malignant Melanoma

◼ ABC’s

Asymmetry

Border Irregularity – may have edges or corners

Color Variation

Diameter - >6mm

Evolving over time/Elevated above skin surface

Firm to Touch

Growing

Malignant Melanoma Subtypes

◼ Superficial Spreading

Most common

Occur on the trunk or extremities

Usually develop from a prior mole

Has a prolonged radial growth phase prior to

vertical growth

Superficial Spreading

MelanomaNodular Melanoma

◼ Most aggressive form of melanoma

◼ 10-15% of melanoma

◼ Grows rapidly in thickness

◼ Often grows de novo instead of from an

existing mole

◼ Raised and darkly pigmented

Nodular Melanoma Lentigo Maligna Melanoma

◼ Found on chronically sun damaged skin

◼ 5-10% of all melanomas

◼ Darkly pigmented flat brown/black lesion

◼ Occurs on face or arms, often in the elderly

◼ Lentigo maligna

non-invasive skin growth considered to be melanoma-in-situ vs a melanoma precursor

LMM is invasive

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Lentigo Maligna

Lentigo Maligna MelanomaAcral Lentiginous Melanoma

◼ ~7% of all melanomas

◼ Average age is 60-70 y.o.

◼ Most common melanoma in Asians and

African Americans

◼ Similar appearance to LMM

◼ Typically occurs on the hands & feet

Acral Lentiginous Melanoma Amelanotic Melanoma

◼ Non-pigmented

◼ 2% of all cases

◼ Often diagnosed later in the course

Amelanotic Melanoma Melanoma Prognosis

◼ Depends on depth

◼ Females and young adults do better

◼ Extremity lesions have a better prognosis

than trunk, head, or neck lesions

The scalp has the worst prognosis

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