Dermatologic Emergencies

Derrick Huang, PGY1

• General approach
• History, Physical, and Red Flags
• Drug Reactions

• Not focusing on full management and disposition

History
• Distribution and progression of the skin lesions
• Recent exposures (sick contacts, foreign travel, sexual history,
vaccinations)
• Immunosuppression
• New medications
Physical
• Toxic Appearance?
• Vital signs - fever or hypotension?
• Undress - trunk and the extremities - palms, soles and
mucous membranes
• Touch - flat or raised, blanches?
• Rub - erythematous skin sloughs?
Four broad categories
• Petechial/Purpuric
• Erythematous
• Maculopapular
• Vesiculobullous

• +/- mucous membrane involvement

• Overlap with cellulitis, erysipelas, necrotizing infections
Petechial/purpuric rashes
SICK OR NOT
FLAT OR PALPABLE
• Meningococcemia: meningitis, rash initially
erythematous, maculopapular – starts at wrist and
ankles, then becomes palpable petechiae spreading
to rest of body, mimicking RMSF
• Vanc/ceftriaxone

• RMSF: tick-Rickettsia rickettsii. Mortality >30%

when untreated or TX
• southeastern or south central US
• Doxycycline in all non-pregnant patients, even
children
• Autoimmune vasculitis: blood vessels attacked by
immune system. inflammation and capillary
leakage producing palpable petechiae
• Rheum - SLE, RA, SS
• Vasculitis - Wegener’s, Churg-Strauss
• Chronic hepatitis C or B
• Meds: penicillins, cephalosporins,
sulfonamides, phenytoin, etc

• ITP: classically with preceding viral illness

• ICH if platelets <10 x 10 ^3/uL
• nonpalpable petechiae - ankles or buttocks -
spread to rest of body
• TX: steroids if <30k, bleeding
Erythematous rashes
Anaphylaxis or not?
Nikolsky or not?
• TEN/SJS: serious drug reaction. sulfa drugs,
anticonvulsants and antivirals, etc. Mycoplasma
pneumonia and CMV
• Sudden onset diffuse erythema with painful skin
and eventual sloughing
• Skin cleavage - full thickness, massive large sheets
• mucous membranes - painful, erosive and crusting
lesions
• TX: DC offending med and IVF, wound care, burn unit
• Toxic shock syndrome: toxin-mediated illness, staph
or strep. majority - MSSA, MRSA increasing.
• Tampon, nasal packing, surgical wounds,
postpartum infection and abscesses
• hypotension refractory to fluids due to massive
vasodilation
• diffuse erythematous rash, eventually
desquamate
• TX: remove source, ABX (Clinda/vanc),+/-
vasoactives, ICU
Maculopapular
Just focus on Peripheral maculopapular
Then Targetoid or not
• Erythema Multiforme (EM):
autoimmune. HSV, mycoplasma or
fungal. Drugs (sulfa, anticonvulsants
and antibiotics
• EM minor = pruritic targetoid
lesions on extremities/palms,
soles, face, extensors
• Resolve in 1-2 wks
• EM major = life threatening –
mucous membranes involved
• TX: DC offending agent, IVF,
analgesics, wound care +/-
systemic steroids
 !!!!!!!

• Maculopapular + Peripheral:
• If not targetoid = assess for meningococcemia and RMSF because both
begin with rashes in maculopapular form before becoming petechial
Vesiculobullous
Fever or not
diffuse or not
• Necrotizing fasciitis: severe soft tissue
infection - systemic toxicity. anywhere on
body - most commonly extremities,
perineum and genitalia; and rarely trunk
• fever, hypotension or toxic
• Disproportionate pain to exam
• Pain, edema beyond margins of
erythema
• indistinct margins
• Early - skin findings mild (cellulitis)
• Later on - skin bullae, skin necrosis and
crepitus.
• TX: IVF, ABX, immediate surgical
debridement
• Bullous pemphigoid: autoimmune skin blisters - elderly
• prodrome phase lasting weeks to months -
eczematous, papular or urticarial skin lesions. Then,
diffuse tense blisters and bullae. tense quality
differentiates from pemphigus vulgaris
• Mucosal lesions in 10-30%
• TX: topical or oral corticosteroid. Derm.

• Pemphigus vulgaris: autoimmune skin blisters - onset

between 40-60 years old
• bullae = flaccid/superficial, coalesce - large areas of
skin sloughing 
• Positive Nikolsky sign
• painful mucosal erosions
• TX: fluid and electrolyte control similar to burn care,
requiring pain control, prevention secondary
infection, treatment with steroids. Derm.
Drug Reactions
• ABCDE of Drug Rashes
• Acute generalized exanthematous pustulosis (AGEP)
• Bullous disease, drug induced (SJS/TEN)
• Captopril (ACE-inhibitor) induced angioedema
• Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome
• Exfoliative erythroderma/dermatitis, Erythema Multiforme

• Generalities:
• Sudden, usually morbilliform, often starts on face & trunk & spreads
• More polymorphous than viral exanthem
• Similar drugs
• All classically with fever + Most with Hepatitis
• ~>1 wk from drug initiation
• All >5% mortality
General Work up and management
• Usually clinical diagnoses, but similar work up (”Sepsis orders”)

• CBC with diff (eosinophilia, WBC)

• CMP (LFTs, Na)
• ESR, CRP (assessing for infection)
• CXR (associated pneumonitis, etc)

• DC drug, Eventually – biopsy

• Wound management, IVF (similar to burns), assess secondary infection risk
• Supportive care: antipyretic, anti-pruritic
• Derm consult for steroids, immunosuppressants
• Admission +/- transfer burn unit
Drug rash with eosinophilia and systemic
symptoms syndrome (DRESS Syndrome)
• Within 8 weeks of new drug
• 8-10% mortality
• Previously - Anti-convulsant hypersensitivity syndrome
• Phenytoin, carbamazepine, allopurinol, sulfa drugs,
NSAIDs, antipsychotics, ABX, etc..
• HHV-6, HHV-7, EBV, and CMV

• Fever + Facial edema, similar to SJS, EM

• Usually urticarial, maculopapular eruption
• Leukocytosis with eosinophilia in 50-90%,
• +/- Lymphadenopathy
• Systemic: hepatitis, pneumonitis, myocarditis,
pericarditis, nephritis, colitis
Stevens-Johnson syndrome and toxic
epidermal necrolysis
• spectrum of disease - blistering and peeling of the skin
• SJS involves <10% of the skin body surface area
• TEN involves >30% of the skin body surface area
• Mortality 5-35%
• Sulfa, quinolones, PCN, acetaminophen, carbamazepine, NSAIDs, phenyt
oin
• Malignancy - lymphoma, brain tumors
• Idiopathic
• HIV, Mycoplasma pneumoniae, SLE

• Prodromal fever, malaise

• Macular rash +/- Target lesions - Usually starts centrally, spreads peripherally,
May have + Nikolsky sign
• Mucous membrane involvement, including eyes, GI, resp tract
• Burn unit, ICU +/- IVIG, plasmapheresis, corticosteroids, etanercept
Acute generalized exanthematous pustulosis
• T-cell mediated rash with systemic features
• Mortality rate of ~5%
• >90% assc medication (usually an antibiotic)
• aminopenicillins, macrolides, cephalosporins
• Onset 1-5 days after starting causative medication
• Rash:
• Large areas of edematous erythema with numerous
small, non-follicular pustules
• Main body folds and upper trunk, +/- face
• NO mucous membrane involvement (VS SJS/TEN)
• Systemic findings: Fever, leukocytosis, hepatitis,
possible eosinophilia
Exfoliative erythroderma/dermatitis
• Diffuse, widespread scaly dermatitis on most of body surface
• 5-15% mortality
• Cutaneous reaction to drug or underlying systemic or
cutaneous disease

• Fever + Erythematous plaques and edema >90% body

surface with or without diffuse exfoliation
• starts on face and trunk
• Abrupt onset if related to drug, contact allergen, or malignancy
• gradual onset if related to underlying cutaneous disorder
• Can be chronic condition, mean duration 5 years
• Hypothermia, high output HF due to diffuse vasodilation
Necrotizing infections/fasciitis
• rapidly progressive infection of fascia and SQ tissue
• Sepsis + Skin exam
• Erythema (without sharp margins)
• Exquisitely tender (pain out of proportion to
exam) unless ischemic nerves
• Hemorrhagic bullae (violaceous bullae)
• Crepitus - not required (ie Group A Strep)

• Surgical ONLY way to definitively establish diagnosis

of necrotizing infection
• Imaging
• Should not delay surgical exploration
LRINEC Scoring
• CRP (mg/L) ≥150: 4 points
• WBC count (×103/mm3)
• <15: 0 points; 15–25: 1 point; >25: 2 points
• Hemoglobin (g/dL)
• >13.5: 0 points; 11–13.5: 1 point; <11: 2 points
• Sodium (mmol/L) <135: 2 points
• Creatinine (umol/L) >141: 2 points
• Glucose >180 mg/dL (10 mmol/L): 1 point
• Low Risk: score 5 (10% with score < 6 still positive)
• score > 6 has PPV of 92% and NPV of 96% for necrotizing fasciitis
• May be better for rule out if everything is negative

ABX covers G+, G-, anaerobes (zosyn, clindamycin, vancomycin), strict glycemic control
References
• Wall DB, Klein SR, Black S, de Virgilio C. A simple model to help distinguish
necrotizing fasciitis from nonnecrotizing soft tissue infection. J Am Coll Surg.
2000 Sep;191(3):227-31. doi: 10.1016/s1072-7515(00)00318-5. PMID: 10989895.
• Wong CH, Khin LW, Heng KS, Tan KC, Low CO. The LRINEC (Laboratory Risk
Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing
fasciitis from other soft tissue infections. Crit Care Med. 2004 Jul;32(7):1535-41.
doi: 10.1097/01.ccm.0000129486.35458.7d. PMID: 15241098.

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