Inpatient Dermatology

sheet-like skin and mucosal loss

SJS <10% BSA, Overlap 10-30%, TEN >30% BSA

incidence: 1-2 affected per million

slightly more common in females. 100X more common in HIV

usually preceded by flu-like illness: aches, pains, fever, sore throat, conjunctivitis

pt typically with marked pain and extremely anxious

mortality rate 10% SJS, 30% TEN; can be more accurately predicted with SCORTEN score

Most common culprits:

Sulfonamides: cotrimoxazole

Beta-lactam: penicillins, cephalosporins

Anti-convulsants: lamotrigine, carbamazepine, phenytoin, phenobarbitone

Allopurinol

Paracetamol/acetaminophen

Nevirapine (non-nucleoside reverse transcriptase inhibitor)

Nonsteroidal anti-inflammatory drugs (NSAIDs) (oxicam type mainly).

cessation of causative / suspect drugs --consider burns unit admission for wound care management

pain management

early involvement derm and ophthalmology teams

system steroids of unclear efficacy given wound care & infection concerns

heated room 30-32degrees

consider alternative diagnoses (DRESS, AGEP)

Heat causes exocrine gland blockage, resulting in raised, itchy rash.

associated with former heating pad sites, abundance of blankets

Take cool baths or showers; tap dry; use cold compresses

Wear loose cotton clothing.

Use lightweight bedding.

Drink plenty of fluid to avoid dehydration.

inflamed small blood vessels due to infiltration of neutrophils into blood vessel walls

rash caused by small areas hemorrhage, resulting in purple red lesions (palpable purpura)

punch biopsy to confirm diagnosis

frequently occurs in association w/ systemic dx: infection, SLE, RA, Sjogren, malignancy

early involvement of dermatology: after confirmation via punch biopsy, treat most likely underlying source of disease

tx often involves systemic corticosteroids

IRegiSCAR inclusion criteria for potential cases require at least 3 of the following:

1. Hospitalization

2. Reaction suspected to be drug-related

3. Acute skin rash

4. Fever above 38C

5. Enlarged lymph nodes at two sites

6. Involvement of at least one internal organ

7. Blood count abnormalities such as low platelets, raised eosinophils, or abnormal lymphocyte count.--morbilliform drug reaction + erythroderma + facial swelling + mucosal involvement

-causative agents: allopurinol (esp together with thiazide), sulfa drugs, carbamazepine, phenobarb, phenytoin, iodinated contrast

-onset ~ 2 weeks of inciting drug

withdraw all suspected meds --systemic corticosteroids with slow prolonged taper

-supportive tx with unscented emollients, topical corticosteroids

rapidly enlarging, painful ulcer, autoinflammatory etiology

full thickness with purple/blue undermined borders

50% cases have an underlying disease pathology, ex: IBD (UC>Chron's), RA, leukemia, IgA gammopathy, GPA, Behcet

mostly non-surgical, though skin grafting may be necessary after active phase

potent topical steroid, tacrolimus ointment, oral doxycycline

large ulcers may require: oral steroids, anti-TNF (anakinra, infliximab, etanercept) -avoidance of local trauma

pathophys: localized staph infection → bacterial exotoxins trigger massive cytokine release, producing rash (sunburn appearance), fever, hypotension

initial phase: diffuse macular rash, "sunburn appearance", fever, multiorgan abnormalities

secondary phase: 1-2 wks later: shedding skin in large sheets

prior toxic shock sis a risk factor for recurrence

-majority of cases are surprisingly previously healthy adults aged 20-50

-complications: ARDS, DIC

peripheral blood cultures to isolate causative strain. Typically, will use penicillin (or Vanc allergy) + clindamycin

skin lesions starting as papules, or pustules. Over course of weeks, develop into ulcerated/crusty sores

heal to form raised wart-like scars

screen all for HIV

when the infection spreads and skin becomes involved, spontaneous resolution does not occur and treatment is necessary.

treat underlying immunosuppressive condition, for example, HIV

ID consult warranted: skin involvement necessitates treatment bc spontaneous resolution does not occur: mild-moderate disease treat with itraconazole, severe disease treat with amphotericin B

centripetal rash: begins on hands/wrists, ankles, spreads centrally towards trunk/abdomen. face typically rash-free in beginning of course. Starts as red macules, then becomes papular and petechial

tx: doxycycline, other tetracyclines. Pregnant females require ID consult.

affects younger demographic than SJS/TEN

causative agent = mycoplasma pneumoniae

-predominant mucosal & occular features, with fewer cutaneous features than SJS/TEN

MIRM criteria:

<10% BSA with detachment:

Few cutaneous vesiculobullous lesions

Atypical pneumonia present

Labs: increase in M. Pneumoniae IgM antibodies, M. Pneumoniae in oropharyngeal or bullae cultures or PCR, and/or serial cold agglutinins

-early Optho and Derm involvement (esp since SJS/TEN should be ruled out):

typically, optho will recommend antibiotic drop QID, cyclosporine BID, steroid drops BID, and combo abx / steroid ointment to eyelid margins BID to QID