Dermatological

Rapid Review

• Background
  • Atopic dermatitis is a chronic relapsing inflammatory skin disorder with a complex pathogenesis involving genetic susceptibility, immunologic and epidermal barrier dysfunction, and environmental factors. 
• Signs/Symptoms
  • Itchy/scaly rash, particularly on cheeks/trunk and flexor surfaces. Pruritus is the primary symptom.
• Diagnosis
  • Clinical diagnosis
• Treatment
  • Identify and eliminate triggers. Topical steroid (hydrocortisone, triamcinolone, etc.). Emollients (Vaseline, Aquaphor) can be used on top of steroids.
• Disposition
  • Most of these patients can be discharged safely
  • Consider referral to dermatology for complex or refractory cases

Pearls

• High potency steroids (ex. Clobetasol, betamethasone) should be avoided on the face or eyelids. Use low potency instead (ex. Hydrocortisone 0.5% or 1%)
• Severe cases may require a course of oral steroids (ex. 20 mg x 7 days). Howeve, this is controversial as the disease tends to relapse quickly once discontinued.

Deep Dive

• Atopic Dermatitis (Merck Manual)

Rapid Review

Pearls

Deep Dive

• Painful Weeping Rash (SAEM)

Rapid Review

• Background
  • Cellulitis is an infection of the soft tissue beneath the skin, most commonly caused by bacteria that normally colonize the skin surface (ex. Staph aureus).
• Signs/Symptoms
  • Tender, warm, erythematous rash with poorly demarcated borders. May have an associated skin abscess. Patients may also experience fever/chills, malaise, or headache.
• Diagnosis 
  • Clinical diagnosis; ultrasound may aid in the diagnosis by showing a “cobblestone appearance” and identifying potential abscesses 
• Treatment
  • Cephalexin or amoxicillin for simple cellulitis. For suspected MRSA, use TMP/SMX, clindamycin, or doxycycline.
• Disposition
  • Mild cases can be safely discharged with PO antibiotics as long as the patient has access to close follow up as needed.
  • Severe cases (sensitive areas, signs of sepsis, tissue necrosis) or those that have failed outpatient treatment will require admission.

Pearls

• Blood cultures are rarely needed for most cases of cellulitis, however you should obtain them if there are any signs of sepsis. 
• Add coverage for MRSA (ex. Clindamycin, doxycycline, TMP-SMZ)  if the cellulitis has a purulent component. Additionally consider it if the patient lives in a long-term care facility, was recently hospitalized, or has had a previous MRSA infection. 

Deep Dive

• Cellulitis (Core EM)

Rapid Review

• Background
  • Contact dermatitis is inflammation of the skin caused by direct contact with irritants (irritant contact dermatitis) or allergens (allergic contact dermatitis). 
• Sign/Symptoms
  • Well-demarcated erythematous rash on site of contact, with possible vesicles or erosions. Rash will typically be pruritic.
• Diagnosis
  • Clinical diagnosis based on history, exam, and exposure history. Allergists/dermatologists may use patch test to determine precise cause.
• Treatment
  • Removal of irritant/allergen, topical steroids (hydrocortisone, triamcinolone), and emollients. 
• Disposition
  • Most patients can be discharged unless the dermatitis is severe or associated with a secondary infection.

Pearls

• It’s important to not only treat the dermatitis, but also attempt to identify the offending agent through careful history so that patient can avoid continued exposure.
• PO steroids (ex. Prednsione 60 mg x 7 days) may be required for severe cases.

Deep Dive

• Contact Dermatitis (Merck Manual)

Rapid Review

Pearls

Deep Dive

• Erysipelas (Merck Manual)

Rapid Review

Pearls

Deep Dive

• Herpes Zoster (NUEM)

Rapid Review

Pearls

Deep Dive

• Hidradenitis Suppurativa: Diagnosis and Management in the Emergency Department (Pubmed)

Rapid Review

Pearls

Deep Dive

Rapid Review

Pearls

Deep Dive

• Impetigo and Ecthyma (Merck Manual)

Rapid Review

• Background
  • Necrotizing fasciitis is a severe bacterial infection that can lead to tissue destruction, systemic infection and death. It is sometimes referred to as “flesh eating bacteria”. It is typically caused by a mix of bacteria that release a toxin which destroys surrounding tissue.
• Signs/Symptoms
  • Pain out of proportion to exam. Erythema, swelling/edema, hemorrhagic bullae, lymphadenopathy
• Diagnosis
  • Ultrasound may show thickened fascia planes. CT is the study of choice, however, surgical exploration is the only definitive method of diagnosing necrotizing fasciitis.
• Treatment
  • Treat initially with broad-spectrum antibiotic coverage (Piperacillin-Tazobactam + Clindamycin + Vancomycin). Surgical debridement required for definitive treatment.
• Disposition
  • All patients will require ICU admission. Consult general surgery early for debridement.

Pearls

• Scoring systems, such as LRINEC, may be useful for ruling in the disease, but cannot be used to definitively rule out necrotizing soft tissue infections.
• Time is tissue! Delays in surgical debridement substantially worsen prognosis. 

Deep Dive

• Necrotizing Fasciitis-Pearls & Pitfalls (emDOCs)

Rapid Review

Pearls

Deep Dive

Rapid Review

Pearls

Deep Dive

• Staph Scaled Skin Syndrome (Pediatric EM Morsels)

Rapid Review

• Background
  • Steven-Johnson Syndrome (SJS) is a severe skin and mucous membrane reaction that causes necrosis and sloughing of the epidermis (top layer of skin). The most common cause is medications, but can also occur due to infection and in many cases the cause is not known. When skin sloughing involves greater than 30% of the body surface, the term toxic epidermal necrolysis (TEN) is used.
• Signs/Symptoms
  • Vesicles and bullae involving < 10% of the body on at least 2 mucosal sites. Patients often experience a prodrome (fever, URI symptoms, headache, and malaise)
• Diagnosis
  • Clinical diagnosis
• Treatment
  • Removal of cause (usually medications), fluid resuscitation, referral to burn center
• Disposition
  • Most patients will require admission to ICU or burn unit.
  • May require consultation with other specialists if sensitive areas are involved (ex. genitalia, eyes, or mouth)

Pearls

• Steven johnson syndrome can sometimes present as flu-like symptoms, with lesions appearing approximately 24-72 hours after prodrome.
• SJS may present anytime between a few days after exposure to a new medication to up to 8 weeks later.

Deep Dive

• SJS and TEN (Merck Manual)

Rapid Review

Pearls

Deep Dive

• Steven Johnson Syndrome and Toxic Epidermal Necrolysis (emDocs)

Rapid Review

Pearls

Deep Dive

• Urticaria (Emergency Care BC)