Derm Emergencies

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    Toxic Epidermal Necrolysis

    • Severe life-threatening skin eruption that is most commonly due to an adverse drug reaction.  (i.e. classically septra)
    • Symptoms:
      • Prodrome: Fever, sore throat, burning sensation in eyes (1-3 days before skin lesions)
      • Skin findings characterized by flat, atypical, purpuric, targetoid lesions that coalesce into dusky, poorly demarcated, confluent patches (TEN “with spots”)
      • or may consist of confluent, tender erythema without identifiable individual lesions (TEN “without spots”). 
      • Involved skin blisters, sloughs, leaving behind denuded drmis.  
    • Physical exam:
      • Nikolsky sign = Lateral pressure on erythematous skin shears off skin (present but not pathognomonic)
      • Mucous membranes involved (not required for dx)
    • Diagnosis:
      • Skin biopsy  --> for frozen section. (confirms dx in hours)
    • Treatment:
      • Do skin biopsy to confirm
      • STOP causative medications (avoid unnecessary medications)
      • Admit to Burn or ICU unit.
      • Supportive care is mainstay
        • wound care
        • fluid/electrolyte management, nutrition
        • monitor superinfections (do not prophylax)
      • Do not use steroids (controversial) (some studies suggest worse morbidity/mortality)




    • Aka:
      • Drug Hypersensitivity Syndrome (DHS)
      • Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS)
    • Aka Drug-Induced Hypersensitivity Syndrome
    • Appears 2-8w of starting new drug
    • Pathophysiology
      • Perhaps drug-triggered viral replication and a pronounced host antiviral response with widespread inflammation
    • Triggers:
      • Sulfonamide antibiotics
      • Allopurinol
      • Anticolvulsants
      • Many Others!!!
    • Symptoms:
      • Fevers
      • Widespread Morbilliform Eruption (often involving face)
        • Facial Edema
      • CBC abnormalities (eosinophilia or atypical lymphocytosis)
      • Systemic Inflammation
        • Lymphadenopathy
        • Hepatitis
        • Nephritis
        • Pneumonitis
        • Myocarditis
        • Hypotension
    • Evaluations:
      • CBC+diff (eosinophilia or atypical lymphocytosis?)
      • Liver Chemistry, Creatinine, Urinalysis
      • Baseline echo (some experts suggest, given severity of myocarditis)
    • Management:
      • STOP Causative Medication
      • Glucocorticoids - Systemic (1-2mg/kg tapered slowly over weeks-to-months)
      • HIGH mortality, evaluate for DRESS/DHS any fever/rash after starting a high-risk medication (5% mortality)
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