This document provides an overview of cutaneous emergencies. It discusses various skin cancers including basal cell carcinoma, Kaposi's sarcoma, melanoma, and squamous cell carcinoma. It also reviews decubitus ulcers, various types of dermatitis (atopic, contact, eczema, psoriasis), fungal infections like candida and ringworm, bacterial skin infections such as abscesses and cellulitis, and parasitic infections. Treatment options are provided for many of the conditions. The document is intended to inform and educate emergency healthcare providers about evaluating and managing different skin emergencies and infections.
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GEMC- Cutaneous Emergency- Resident Training
1. Project: Ghana Emergency Medicine Collaborative
Document Title: Cutaneous Emergencies
Author(s): Joe Lex, MD, FAAEM, FACEP (Temple University) 2013
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7. Basal Cell Carcinoma
Nodular UlceratingPigmented
Kuebi,
Wikimedia Commons
Kuebi, Wikimedia Commons National Institutes of
Health, Wikimedia
Commons
8. Basal Cell Carcinoma
James Heilman, MD, Wikimedia Commons
National Institutes of Health, Wikimedia
Commons
9. Kaposi’s Sarcoma
• Painless, raised brown-black or
purple papules and nodules that
do not blanch
• Face, chest, genitals, and mouth
• Not associated with increased
morbidity or mortality
• Referral if bothersome
10. Kaposi’s Sarcoma
Classic KS: elderly
male Ashkenazi and
Mediterranean Jews
HIV-associated:
homosexual men
Kuebi, Wikimedia Commons
National Institutes of Health,
Wikimedia Commons
11. Melanoma RISK
Risk factors
• Moles: atypical or common
• Red hair and freckling
• Inability to tan
• Sunburn: severe sunburn
especially before age 14
• Kindred: family history
12. Melanoma
Melanoma in situ
Superficial spreading
melanoma
Melanocytic nevus
Centers for Disease Control and
Prevention, Wikimedia Commons
National Cancer Institute, Wikimedia
Commons
National Cancer Institute,
Wikimedia Commons
13. Melanoma
• Early detection = early cure
• Have low threshold, refer if
suspected
0x6adb015, Wikimedia Commons
14. Squamous Cell Carcinoma
• Sunlight
exposure
• Age >55
• Men > women
• White > Black
National Cancer Institute, Wikimedia Commons
15. Squamous Cell Carcinoma
Treatment
• Surgery
• Radiotherapy
• Cryotherapy
• 5-fluorouracil
• 90% cure rate if
treated early
Almazi, Wikimedia Commons
16. 2. Decubitus Ulcer
• External compression of dermis
and hypodermis ischemic
tissue damage and necrosis
• Risk factors: inadequate nursing
care, diminished sensation /
immobility, hypotension, fecal /
urinary incontinence, low serum
albumin, poor nutrition
17. Stages of Ulcers
I: Nonblanching erythema of intact
skin
II: Necrosis, superficial or partial-
thickness involving epidermis
and/or dermis. Bullae necrosis
of dermis (black) shallow ulcer
18. Stages of Ulcers
III: Deep necrosis, crateriform
ulceration, full-thickness skin loss;
extends to, but not through, fascia
Source Undetermined
19. Stages of Ulcers
IV: Full-thickness ulceration with
extensive damage / necrosis to
muscle, bone, support structures
Essent, Wikimedia Commons
20. Management
• Stage I and II: topical antibiotics
under moist sterile gauze
• Stage III and IV: surgical
debridement and repair
• Complications: osteomyelitis,
sepsis with resistant organisms
(VRE, MRSA, etc.)
26. Contact Dermatitis
Generic term applied to acute or
chronic inflammatory reactions to
substances that come in contact
with the skin
•Chemical irritant
•Allergic caused an antigen that
elicits a type IV (cell-mediated or
delayed) hypersensitivity reaction
29. Contact Dermatitis
• Gauze soaked in Burow’s solution
changed every 2 to 3 hours
• Class I topical corticosteroid
preparations may be effective if
nonexudative, nonbullous
• Systemic corticosteroids if severe
(cannot function or sleep) or for
exudative lesions
37. Psoriasis – Findings
• Bilateral, often symmetrical; often
spares exposed areas; favors
elbows, knees, scalp, and
intertriginous areas; face
involvement uncommon
• Guttate psoriasis: disseminated
small lesions without predilection
of site
53. Hidradenitis Suppurativa
• Chronic, suppurative disease of
apocrine gland–bearing skin in
axillae and anogenital region
• Tender, red nodules not related to
hair follicles
• Acute lesions: incise and drain
• Refer for definitive care
55. Cellulitis and Erysipelas
• Acute, spreading infections of
dermal and subcutaneous tissues
• Red, hot, tender skin, often at site
of bacterial entry
• Cause: group A beta-hemolytic
streptococci or Staphylococcus
aureus
56. Cellulitis and Erysipelas
Treatment: outpatient
• Dicloxacillin
• Macrolide: EES, azithromycin,
clarithromycin
• Amoxicillin-clavulanate
• Clindamycin
• TMP-SMZ
60. Impetigo and Ecthyma
• Superficial infection of epidermis
by Staphylococcus aureus and
Streptococcus pyogenes
• Extension into dermis
ecthyma, crusted erosions
or ulcers
91. Scabies
• Permethrin 5% cream (Elimite®)
or lindane 1% lotion (Kwell®)
• Leave on overnight, rinse off in
morning
• Lindane easier to apply, less
expensive, but some resistance
• Lindane neurotoxic to infants
105. Herpes Simplex
Centers for Disease Control and Prevention,
Wikimedia Commons
James Heilman, MD, Wikimedia
Commons
106. Herpes Simplex
• Antivirals more effective in
primary infection than recurrence
• Acyclovir (Zovirax®) 400 mg TID
or 200 mg 5 times daily
• Valacyclovir (Valtrex®) BID
• Famciclovir (Famvir®) TID
107. Herpes Zoster
• Varicella Zoster Virus (VZV)
• “Shingles”
• Prodrome: flu-like symptoms prior
to rash
• Depression very common
108. Herpes Zoster
Fisle, Wikimedia Commons Jonathan Trobe, M.D. - University of
Michigan Kellogg Eye Center, Wikimedia
Commons
109. Herpes Zoster
• Herpes zoster ophthalmicus: CNV
–Vision-threatening condition
–Hutchinson sign: lesions on tip of
nose nasociliary nerve
• Ramsay Hunt syndrome: CNVII
–Facial palsy resembling Bell palsy
–Vesicles in ear canal or on tympanic
membrane
113. Human Papillomavirus
• Treatment: conservative, since
spontaneous remission is the rule
• Aggressive if symptomatic (e.g.
plantar, genital)
–Podofilox 0.5% (Condylox®) gel or
solution BID x 3 days no therapy
x 4 days repeat up to 4 cycles
–Cryotherapy
114. Molluscum Contagiosum
• Poxvirus umbilicated papules
• Normal host: cosmetic problem,
spontaneous remission
• Immunocompromised host:
require HAART (Highly Active
AntiRetroviral Therapy) to avoid
widespread dissemination
117. Rocky Mountain Spotted Fever
• Only in Western hemisphere
• Highest US incidence: Oklahoma,
North Carolina, Virginia, Maryland
• Rarely in Rocky Mountains
• Incubation: 3 to 14 days
• Prodrome: anorexia, irritability,
malaise, chills, fever
118. Rocky Mountain Spotted Fever
• History of tick bite ~60%
• Onset abrupt: fever (94%), severe
headache (86%), myalgias
especially back and legs (83%)
• First illness day: 14% have rash
• First 3 days: 49% have rash.
• 13% no rash (spotless RMSF)
119. Rocky Mountain Spotted Fever
• Early lesions: 2 to 6 mm, pink,
blanchable macules
• Evolve to deep red papules
• In 2 to 4 days: hemorrhagic, no
longer blanchable
• Rarely: eschar
120. Rocky Mountain Spotted Fever
RMSF macules RMSF papules
Centers for Disease Control and Prevention,
Wikimedia Commons
Source Undetermined
123. Immune Thrombocytopenic Purpura
• Common and
early site: palate
• Palatal petechiae
also seen in…
…strep throat
…mononucleosis
…rubella (measles)
Centers for Disease Control and
Prevention, Wikimedia Commons
124. German Measles (Rubella)
• Young adults
• Droplet spread
• No prodrome
• 14 – 21 day
incubation
• Lymph nodes
+/- arthralgias
Centers for Disease Control and
Prevention, Wikimedia Commons
126. Chicken Pox (Varicella)
• 90% <10 years old
• Incubation 10 – 23
days
• Prodrome
uncommon
• Very itchy
• “Dewdrop on a
rose petal”
Camiloaranzales, Wikimedia
Commons
141. Erythema Multiforme
• Systemic steroids: symptomatic
relief, but don’t change duration
or outcome
• Extensive disease or mucous
membranes involvement
hospitalize in ICU or burn unit
• Eye involvement: ophthalmology
142. Erythema Nodosum
• Inflammatory /
immunologic
reaction of
panniculus
• Painful nodules
on lower legs
• Multiple and
diverse causes
James Heilman, MD, Wikimedia
Commons
156. Urticaria and Angioedema
• Urticaria: wheals transient
edematous papules and plaques,
usually pruritic, due to edema of
papillary body
• Angioedema: larger edematous
area involving dermis and
subcutaneous tissue
159. Urticaria
• Urticaria = hives
• Cutaneous IgE-mediated
• Treatment
–Epinephrine + antihistamines +/-
steroids
–H2 receptor blocker if severe
–Cool compresses: soothing
• Refer to allergy specialist
160. Angioedema
• Angioedema of tongue, lips, face
in 0.1 to 0.2% of patients taking
ACE-inhibitor
• Management supportive, special
attention to airway
• Usual allergic-reaction drugs not
proven beneficial
167. Lymphangioma
• Multiple small fluid-
filled vesicles
(“frog-spawn”)
• Present at birth or
appears in infancy
or even in childhood
• No spontaneous
regression
Source Undetermined
168. Lipoma
• Benign subcutaneous tumor
• Soft, rounded, or lobulated
• Movable against overlying skin
• May become large
• Composed of fat cells
171. Nikolsky’s Sign
• Epidermis
dislodged by
gentle finger
stroke near blister
• Pressure on
blister lateral
extension of
subdermal fluid
Source Undetermined
172. Pemphigus Vulgaris
• Autoimmune, often fatal
• Age 40 to 60
• Treatment: high-dose steroids
• Other immunosuppression:
azathioprine, cyclophosphamide,
plasmapharesis, methotrexate,
etc.
190. Delusional Parasitosis
1. Suffered from infestation for long
time
2. Seen by numerous physicians,
exterminators, parsitologists,
hygienists and entomologists
3. Consistently and fiercely reject
negative findings or any that
deviate from their perceptions
191. Delusional Parasitosis
4. “Matchbox sign"
– Containers of dust, lint, skin
scrapings, toilet paper, dried blood
or scabs, hair or other pieces of
human tissue
5. Self mutilation ranging from
scratches to deep ulceration
– From attempting to dig out bugs
192. Delusional Parasitosis
6. One or more family members
may share delusion
– Folie à deux / Folie à trois
7. Use of home remedies, distrust
of prescription drugs
8. Self exposure to often
dangerous levels of pesticides
193. Delusional Parasitosis
• Similar to “cocaine bugs”
– Patient feels parasites crawling
under his skin
• Also associated with high fever,
extreme alcohol withdrawal
– Often associated with visual
hallucinations of insects
195. Morgellon’s Syndrome
1. “Filaments” in and on skin
2. Movement sensations, both
beneath and on skin
3. Skin lesions: spontaneously
appearing and self-generated
4. Musculoskeletal pain and
headaches
196. Morgellon’s Syndrome
5. Aerobic limitation: universal and
significant
6. Cognitive dysfunction: short-
term memory and attention
deficit
7. Emotional effects: loss of
boundary control