Embed Size (px)
Citation preview
Hospital Based Practice – Blistering skin conditions.
Skin failure.o Dehydration
o Poikilothermia.
Loss of temperature controlo Infection
o Hypoalbuminaemia
o High utput cardiac failure
o Oedema
Erythroderma Defined as erythema covering > 90% Complication of.
o Eczema
o Psoriasis
o Drug reactions
Can cause.o Dehydration
o Poikilothermia
o Septicaemia
o Hypoalbuminaemia
o High output cardiac failure
o Oedema
Management.o Establish cause.
o Rehydrate
o Adquate nutrition
o Temperature control
o Monitor for septicaemia
o Urgent dermotolgy referral.
Blistering Causes.
o Epidermolysis bullosa
o Pemphigus
o Pemphigoid
o Toxic epidermal necrolysis
o Acute dependent oedema
Complications.o Dehydration
o Poor nutrition
o Septicaemia
o Pain
Management.o Hydration & nutrition
o Monitor for infection
o Analgesia
o Burst blisters
o Urgent dermatology referral
Eczema Herpeticum. Diagnosis.
o History of atopic eczema
o Toxic
o Pyrexial
o Punctate erosions on face and upper trunk.
Investigations.o Viral & Bacterial swabs.
o FBC
o CRP
Management.o IV Aciclovir
o NEVER topical steroids
Complications.o Encephalitis.
Facial Cellulitis. Presentation.
o Toxic
o Pyrexial
o Asymetrical facial swelling.
Red Tender
o Point of entry for infection.
Investigations.o Temperature
o Swabs
o Blood cultures
o FBC
o CRP
Differentialso Acute facial eczema
o Rosacea
o SLE
Management.o IV antibiotics.
o Eg. benzylpenicillin
Complications.o Cavernous sinus thrombosis
Cellulitis. Presentation.
o Toxic
o Pyrexial
o Swelling.
Unilateral Painful Hot
o Point of entry for infection.
Investigations.o |Blood cultures
o Swab
o FBC
o CRP
Differentials.o Varicose eczema
o Gravitational syndrome
o DVT
o Psoriasis
Management.o IV antibiotics.
Benzylpenicillin Flucloxacillin
o Analgesia
o Elevate leg
Acute Eczema. Classify.
o Atopic
o Infected
o Phototoxic
o Allergic
o Exfoliative.
Investigations.o Swab
o Patch test.
When settled Management
o Emollient
o Topical steroids
o Antibiotics.
Acute Psoriasis Diagnosis.
o Guttate
o Pustular
o Erythrodermic
Triggers.o Strep. Pharyngitis
o Drugs.
Lithium Beta – blockers NSAIDs
Management.o Emollient
o Refer to dermatology.
Cutaneous vasculitis. Diagnosis.
o Painful
o Palpable
o Purpura.
Investigations.o Causes.
Infection Drugs Endogenous Autoimmune disease
o Systemic involvement.
Urinalysis eGFR LFTs CXR
Pyoderma gangrenosa. Presentation.
o Begins as pustules
o Rapidly progress to ulcer.
o Ulcer edge is
Inflammed Bluish Undermined
Associated conditions.o Inflammatory bowel disease
o Rheumatoid disease
o Monoclonal gammopathy
Management.o Systemic steroids.
Skin ulcers. Ulcers are abnormal breaks in an epithelial surface. Leg ulcers affect 2% of the population in developed countries. Causes.
o Venous disease
o Arterial disease.
Large vessel disease Small vessel disease
o Neuropathy
o Diabetes.
Neuropathic Vascular
o Lymphoedema
o Vasculitis
o Malignancy
o Infection.
TB Syphilis
o Trauma
Pressureo Pyoderma gangrenosum
o Drugs.
o May be multiple causes.
o For leg ulcers.
70% are venous 15% are mixed venous and arterial 2% are arterial.
History.o Length of history
o Number of ulcers.
o Pain
o History of trauma
o Co – morbidities.
Varicose veins Peripheral artery disease Diabetes Vasculitis
o Is the patient particularly odd?
Consider self – inflicted ulcers. Dermatitis artefacta
Examination.o Note features such as.
Site Number Surface area Depth Edge Base Discharge Lymphadenopathy. Sensation Healing.
o If ulcer is in the legs, look for evidence of venous insufficiency.
Check Ankle – Branchial pressure index.
o Site.
Gravitational ulcers. Tend to occur just superior to medial malleolus. Mostly related to superficial venous disease. May reflect venous hypertension
o Via damage to deep vein valves
eg. Secondary to DVT. Venous hypertension.
Leads to development to superficial varicosities and skin changes.o Eg. Lipodermatosclerosis.
Skin Induration Pigmentation Inflammation
Minimal trauma to leg leads to ulceration.o May take many months to heal
o Temperature.
Ulcer and surrounding tissue is cold in ischemic ulcers Warm and well perfused ulcers tend to have local causes.
o Surface area.
Draw map of the area to quantify and time any healing. Wound > 4 weeks old is a chronic ulcer, compared with a acute ulcer.
o Shape.
Unusual morphology is often due to underlying mycobacterium infection. Cutaneous TB Tuberculosis colliquativa cutis.
o AKA scrofuloderma.
o Infected lymph node ulcerates to the skin.
o Depth.
If not uncomfortable for patient, a probe can be used to measure depth. Most commonly can be performed with neuropathic ulcers.
o Discharge.
Culture any discharge before staring antibiotics. Antibiotics rarely work anyway. Watery discharge is said to favour TB Bleeding discharge normally indicates malignancy.
o Edge.
Eroded edge Suggest active and spreading disease.
Shelved or sloping edge. Suggests healing.
Punched out edge. Syphilis Ischemic
Rolled over/ everted edge. Malignancy
Undermined edge. TB
o Base.
Any muscle, bone or tendon destruction. Malignancy Pressure sores. Ischemia
May be a grey – yellow slough. Overlying pale pink base.
Slough. Mixture of
o Fibrin
o Cell breakdown products
o Serous exudates
o Leucocytes
o Bacteria
o Doesn’t necessarily imply infection
o Part of the normal healing process.
Granulation tissue. Deep – pink gel – like matrix. Contained within fibrous collagen network. Part of normal wound healing process
o Associated lymphadenopathy.
Suggests. Infection Malignancy
o Position in extension/ healing.
Healing is heralded by. Granulation Scar formation Epithelialization
Inflamed margins indicates extension.
Investigations.o Skin and ulcer biopsy.
Vasculitis Maligant changes Ward’s test.
Doppler probe in centre of ulcer.o Look for underlying systemic disorders.
Management.o Often difficult and expensive.
o Treat cause.
o Focus on prevention.
Optimise nutrition Reduce risk factors.
Drug addiction Smoking
Expert nursing care Community nursing team Varicose leg ulcer clinic 4 – layer compression bandaging.
o Systemic antibiotics rarely is effective.
o Topical agents can help.
Silver sulphadiazine Gentamicin.
Brown pigmented lesions. Causes include.
o Melanoma
o Sun – related freckles.
o Lentigos.
AKA moles. Persistent brown macules Often large than freckles.
o Cafe – au – lait spots.
Faint brown macules. If > 5, consider neurofibromatosis
o Seborrhoeic keratoses/ warts.
Benign greasy – brown warty lesions. Usually on the
Back Chest Face
Very commonly in the elderly.o Chloasma.
AKA melasma Brown patches. Especially on the face. Related to pregnancy or pill use. May respond to topical azelaic acid.
o Systemic disease.
Addison’s disease. Palmar creases Oral mucosa Scars
Haemochromotosis Porphyria cutanea tarda.
Brown lesions Fragile skin Blisters.
