Although uncommon, dermatological emergencies are important to recognize in clinical practice, as they can be life-threatening and easily missed.
This article will cover three dermatological emergencies:
Eczema herpeticum is a complication of atopic eczema that occurs with infection of the herpes simplex virus (HSV).
Eczema herpeticum is thought to be due to a reduced level of immunity to HSV in patients with atopic dermatitis.
EH can affect any age, but is most commonly seen in infants and children. It is also more common in those with severe atopic dermatitis/eczema.
Other conditions related to EH include burns, pemphigus vulgaris, and cutaneous T-cell lymphoma.
Typical symptoms of eczema herpeticum include general malaise, fever, new itchy, painful lesions, and gritty or sore eyes (if eye involvement is present). Symptoms tend to develop 5-12 days following contact with HSV.
Typical clinical findings of eczema herpeticum include groups of itchy painful blisters, erosions, and crusted papules, local lymphadenopathy near the site of the lesions, and evidence of secondary bacterial infection (e.g. cellulitis/impetigo).
The clinical presentation of eczema herpeticum can be mistaken for impetigo. The typical golden crusting of impetigo can also mask the primary herpetic lesions.
Diagnosis is mainly based on clinical findings. However, viral and bacterial swabs can be taken from the base of a new blister.
All patients with eczema herpeticum should be referred to a dermatologist for urgent assessment. If there is any ocular involvement an ophthalmology review should also be requested.
Erythroderma is a condition characterized by intense redness of the skin covering at least 90% of the body surface area. It is usually precipitated by pre-existing inflammatory skin disease such as psoriasis. Symptoms include hot, erythematous skin, desquamation, peeling of the skin, and generalized lymphadenopathy.
Mainstays of treatment include emollients and cool, wet dressings. Treatment for any underlying causes may include discontinuance of suspected triggering medications and topical corticosteroids. If a patient with erythroderma is systemically unwell, they may require admission to a specialist burns unit or intensive care unit.
Risk factors include pre-existing inflammatory skin diseases such as psoriasis or eczema, the recent commencement of a new drug, or cutaneous lymphoma.
The diagnosis of erythroderma is usually clinical. However, baseline observations and blood tests should be completed, with a skin biopsy as necessary to clarify the diagnosis.
Patients should be nursed in a warm room (~30°C) and have their fluid balance, electrolytes and body temperature monitored closely.
Complications of erythroderma can include:
Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are variants of the same condition. These are severe mucocutaneous reactions, almost always secondary to medications.
The mechanisms behind SJS and TEN are not yet fully understood. The most common causes are medications, such as allopurinol, anti-epileptic drugs, sulfonamides, antivirals, nonsteroidal anti-inflammatories, salicylates, sertraline, and imidazole.
SJS and TEN are more common in females and those with HIV, and can be triggered by infections such as mycoplasma and cytomegalovirus.
Typical symptoms of SJS and TEN include a prodromal flu-like/non-specific upper respiratory tract illness, a painful rash starting on the trunk which spreads onto the face and limbs, mouth ulcers or soreness, and painful or irritated eyes. It is important to cover drug history (e.g. newly commenced medication -symptoms can occur 5-28 days after starting the causative medication) and past medical history.
Typical findings include a rash which starts as macules, progresses to blisters, and eventually sheets of desquamation. Nikolsky's sign is positive, with gentle rubbing of the skin resulting in desquamation. There can also be ulceration, erythema, and blistering in the oral cavity, and conjunctivitis or corneal ulceration.
Toxic epidermal necrolysis (TEN) is a life threatening dermatological reaction which manifests as a painful, erythematous, blistered rash involving at least 30% body surface area.
In young children, staphylococcal scalded skin syndrome can present with similar clinical features and requires a skin biopsy with histology for definitive diagnosis.
The diagnosis is usually made clinically, but a skin biopsy is required to confirm the diagnosis. The condition is then stratified based on percentage body surface area of the detached epidermis. Refer to Table 1. for categorisations of SJS and TEN.
Patients typically require hospital admission, urgent dermatology referral, and admission to a specialist burns unit or intensive care unit. Any suspected causative medications should be stopped. Fluid balance and electrolytes should also be monitored closely, and patients will require adequate analgesia due to the extreme pain.
Ophthalmology input is necessary if there is evidence of ocular involvement, such as corneal ulceration.
Complications of SJS and TEN may include dehydration or hypovolaemic shock, secondary infection of the skin or mucous membranes, sepsis, disseminated intravascular coagulation, thromboembolism, or death (mortality rates are approximately 10% for SJS and ~30% for TEN).⁵
Hospital admission is required for those who are systemically unwell with close monitoring of fluid balance and electrolytes. Treatment options include emollients, wet wraps and topical corticosteroids.
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