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General ‘Bump’ Terms

Those Bumps aren’t Moguls! An Algorithmic Approach to Rashes David Robinson MD Department of Emergency Medicine University of Texas Medical School at Houston 31rst Annual Emergencies in Medicine Conference Park City, Utah. General ‘Bump’ Terms.

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General ‘Bump’ Terms

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  1. Those Bumps aren’t Moguls!An Algorithmic Approach to RashesDavid Robinson MDDepartment of Emergency Medicine University of Texas Medical School at Houston31rst Annual Emergencies in Medicine ConferencePark City, Utah

  2. General ‘Bump’ Terms • Rash: An eruption on the skin; more extensive than a single lesion • Lesion: Single small, diseased area • Macule: Circumscribed area of change without elevation • Papule: Solid raised lesion ≤1 cm • Plaque: Circumscribed elevated confluence of papules ≥1 cm • Nodule: Solid raised lesion ≥1 cm • Pustule: Circumscribed area containing pus • Vesicle: Circumscribed fluid-filled area ≤1 cm • Bulla: Circumscribed fluid-filled area ≥1 cm • Petechia: Small red/brown macule ≤1 cm that does not blanche

  3. 4 Major Rash Algorithms a. Erythematous b. Vesiculo-bullous c. Petechiae/Purpura d. Maculopapular

  4. Your working at ABEM general when… • ‘sick baby with red skin in room 5’ • Red Skin, ‘skin is peeling off – when I push on it’, blisters • Fever • The 2 key historical points?

  5. Erythematous Rashes Erythema (from the Greek erythros, meaning red) is redness of the skin, caused by hyperemia of the capillaries in the lower layers of the skin

  6. Erythematous Rash

  7. Erythematous Rash with feverPositive Nikolsky Sign – the sick ones • Staph SSS (children <5) • Aka dermatitis exfoliativaneonatorum • Diffuse scarlatiniformerythema • No mucous membranes • Shallow skin cleavage • TEN (adults) • MC associated with sulfa drugs • First around face/eyesshoulders and UE • Mortality 30-35%

  8. Erythematous Rash with feverNo Nikolsky sign • Toxic Shock Syndrome • Diffuse erythematous rash • Kawasaki Disease • High fever x 5 days • Red eyes, Cracked lips, Dry tongue • Scarlet Fever • Pink-red ‘sandpaper’ rash • Flushed face, strawberry tongue • Follows sore throat or impetigo

  9. Erythematous Rash

  10. Erythematous Rash, No Fever and No Nikolsky Sign • Anaphylaxis • 2 or more body systems • Scombroid poisoning • Spoiled dark fleshed fish • Intense histamine reaction 30-40 min after ingestion • Flushing, headache, abd cramps • Self limited, antihistamines • Alcohol Flush • MC seen in Asians (East) • Self limited http://dermatology.cdlib.org/126/case_presentations/scrombroid/ferran.html

  11. Erythematous Rash, +/- Fever and (+) Nikolsky Sign • Toxic Epidermal Necrolysis (TEN) • Associated with drugs • Life threatening shearing of epidermis from dermis in more than 30% of body • Affects mucous membranes • TX: plasmaphoresis, IVIG, stop drug, ICU admit http://dermatology.cdlib.org/126/case_presentations/scrombroid/ferran.html

  12. A two-fer… Bed 3 Bed 9 60 yo with sharp back and chest pain Blisters over specific area of chest – follows dermatome No fever • 6 yo with fluid filled vesicles on face, scalp, torso, upper arms • Fever • unvaccinated Fever and rash distribution What are the diagnostic clues ?

  13. Vesiculo-Bullous Rash Definitions: Circumscribed fluid filled sac less than 1 cm (vesicle) or greater than 1 cm (bullous) Bullous erythema multiforme Vesicles of Hand, foot and mouth

  14. Vesiculo-Bullous Rash

  15. Vesiculo-Bullous rashFebrile and Localized • Necrotizing Fasciitis • Rapidly progressing • Polymicrobial, gpAstrept IV ABX • Hand, Foot and Mouth • Children <10 • Coxsackie A16 • Vesicles to hands, feet • Symptomatic tx http://upload.wikimedia.org/wikipedia/commons/6/6a/Necrotizing_fasciitis

  16. Vesiculo-Bullous rashFebrile and Diffuse • Varicella/ Chicken pox • Smallpox • Variola v • Born after 1972? • Disseminated GC • Also seen as palpable purpura • PurpuraFulminans / DIC • Fever, shock, rapid SQ hemorrhage, tissue necrosis, DIC • MC meningococcal or G(-) organisms • Trauma, multiorgan failure

  17. Vesiculo-Bullous Rash

  18. Vesiculo-Bullous rashNot Febrile and Localized • Contact Dermatitis • Often linear at point of irritation • Zoster • VZV • Follows dermatome pattern • Burns • Dyshidrotic Eczema • Pruritic blisters on hands and feet, possibly scaly • Unknown etiology

  19. Vesiculo-Bullous rashNot Febrile and Diffuse • BullousPemphigus (~60s) • NegNikolsky’s, pruritic • Oral lesions in 1/3 • PemphigusVulgaris (>40 y) • Autoimmune blistering of skin (flaccid bullae) and mucous membranes • Penicillamine, ACE inh • Treat as burns, immunosuppressant therapy

  20. Hey Doc…I got these Bumps on my skin • Afebrile • What are the distinguishing features for these ‘bumps’ • Are they Bumps? • Palpable or Nonpalpable? • Do they Blanch?

  21. Petechial / Purpuric rash Petechia: small (< 3 mm) red or purple spot on body due to minor hemorrhage of blood vessel Purpura: Larger hemorrhagic lesions (3-10mm) Ecchymosis: largest (>10mm)

  22. Petechial / Purpuric rash

  23. Petechial / Purpuric rashFebrile and… Palpable • Meningococcemia • Hemorrhagic, petechial with bullae • From endotoxin release • Disseminated GC • Endocarditis • Osler’s nodes, roth spots, palpable purpura • RMSF • Early: Small, flat non-pruriticmacules on wrists forearms and ankles • Late: spreads to trunk, petechial • HSP • Kids (2-10) • Vascular palpable purpura • Assoc. GI and joint pain

  24. Petechial / PurpuricFebrile and Not Palpable • TTP • Microangiopathic hemolytic anemia, neurologic sx, HUS • Tx with plasma exchange, immunosuppressants • 2° TTP assoc with ca, platelet agginh, immunosuppresants, HIV, SLE • PurpuraFulminans / DIC • Associated with G- sepsis • Debridement, eschar/amput often necessary • HSP (anaphylactoidpurpura) • Systemic vasculitis, children • Associated with infection (pharyngitis) • Triad: purpura, arthritis, abd pain

  25. Petechial / Purpuric rash

  26. Petechial / Purpuric rashNot Febrile and… Palpable Not Palpable ITP (idiopathic thrombocytopenic purpura) Autoimmune in 60% ½ new cases in children, 70% end in remission • Vasculitis • Vascular damage to capillary sized vessels

  27. What are these bumps? Macule: Circumscribed area of change without elevation Papule: Solid raised lesion ≤1 cm Nodule: Solid raised lesion ≥1 cm Plaque: Circumscribed elevated confluence of papules ≥1 cm Morbilliform: has both macular and papular features Drug eruption Pityriasis

  28. Maculopapular Rash

  29. Maculopapular Rash and Fever

  30. Maculopapular Rashwith Fever and Central distribution • Viral exanthum • From Gr: ‘breaking out’ • Measles, rubella, erythemainfectiosum, roseola… • Lyme Disease (erythema migrans) • Target lesions (EM) 3-30 d after bite • Progresses to neuro (10-15%), cardiac complications

  31. Maculopapular RashwithFever and Peripheral Distribution Target Lesions No Target Lesions Meningococcemia RMSF Syphilis Lyme Disease • Stevens-Johnson Syndrome (SJS) • Caused from drugs, infections, malignancies • Erythemamultiforme Clinical presentation, history, and presence of toxicity or neurologic deficits will clue the practitioner to the correct diagnosis

  32. Maculopapular Rash and No fever

  33. Maculopapular RashNo Fever and Central Lesions • Drug Reaction • Fixed or centrally located • Pityriasisrosea • Assoc. with URI, ha, n,v • Herald’s Patch (2-10 cm oval red) seen • Last 6 weeks

  34. Maculopapular RashNo Fever and Peripheral Lesions Lesions on Flexor Surfaces Lesions on Extensor Surfaces Psoriasis Immune mediated, pruritic Red and white scaly plaques, patches 30% with arthritis Tx with ointments, cr, phototherapy • Scabies • Eczema

  35. Bonus clues to bump identification Clues to Diagnosis Rash Patient Age 0 to 5 years: Meningococcemia, Kawasaki disease, viral exanthem >65 years: Pemphigusvulgaris, sepsis, meningococcemia, TEN, SJS, TSS Rash Characteristics Diffuse erythema: Staphylococcal SSS, staphylococcal or streptococcal TSS, necrotizing fasciitis Mucosal lesions: EM major, TEN, SJS, pemphigusvulgaris Petechiae/purpura: Meningococcemia, necrotizing fasciitis, vasculitis, DIC, RMSF Symptom Hypotension Meningococcemia, TSS, RMSF, TEN, SJS

  36. Key Summary Points • Rash with fever is a bad thing • Organize rashes to the 4 major types: • erythematous • macular/papular • petechial/purpura • vesicular-bullous • Secondary signs (Nikolsky, distribution, location (peripheral vs central, extensor vs flexor)

  37. Now, go hit those bumps

  38. References and Acknowledgments • Hanson, S, Nigro, J. Pediatric Dermatology. Medical Clinics of North America. 82(6):1381-1403, 1998 • Lampell, MS.Childhood Rashes that Present to the ED. Pediatric EM Practice. EBMedicine.net 4:3,2007 • CDC homepage (www.cdc.gov/meningitis) • Papulosquamous Diseases. dermatitis emedicine.medscape.com/article/1108312-overview • Murphy-Lavoie, HM. “Approach to Rashes”. Notes from lecture Oct 27,2008 . ACEP Scientific Assembly • Special thanks to Dr. Ronald Rapini, MD Chair, Dermatology at University of Texas Medical School at Houston for various photos

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