Rosen & Barkin's 5-Minute Emergency Medicine Consult (598 page)

See Etiology.

TREATMENT

Universal precautions, masks if infectious etiology suspected

Aggressive, presumptive management of potentially lethal presentations:

• Petechial lesions
  
• Disseminated erythematous or vesicobullous lesions
  
• Purpura with systemic symptoms
  
• Erythroderma with systemic symptoms
  

• Treatment directed by underlying cause
  
• Immediate empiric antibiotics targeted toward meningococcemia and RMSF in unstable patients with fever and purpura
  
• Treat disseminated bullous or exfoliative disease as a severe thermal burn.
  
• Symptomatic treatment of pruritus (diphenhydramine or hydroxyzine)
  
• Steroid therapy reserved for clear allergic reactions, relapse of known steroid responsive disease, or in consultation with dermatologist
  
• Allergic reactions:
  
  • H
    ₁
    -blocker
    
  • H
    ₂
    -blocker
    
  • Steroids
    
  • Epinephrine if respiratory compromise
    

• Prednisone: 1 mg/kg (max. 60 mg/d)
  
• Diphenhydramine: 25–50 mg PO/IM/IV q6h
  
• Hydroxyzine: 25–100 mg PO q6h
  
• Methylprednisolone: 125 mg IV q24h
  
• Topical steroids: Classes 3–5 depending on location and severity
  

FOLLOW-UP

• Patients with significant bullous/exfoliative disorders
  
• Associated systemic symptoms
  

• Limited lesions
  
• Viral exanthems
  
• Absence of systemic signs or symptoms
  
• Stable, chronic presentation
  

Discharge to follow up with primary care physician or dermatologist

• Reassure patients that rashes that cannot be diagnosed in the ED are often due to a mild viral illnesses or allergic reactions
  
• Stress the importance, however, of a follow-up visit with their physician or a dermatologist to obtain the best possible outcome.
  
• The patient should see his doctor quickly or return to the ED if the condition worsens:
  
  • Spreading redness from the rash
    
  • Increasing pain from the rash
    
  • Joint pain
    
  • Spreading of the rash with crusting
    
  • Fever
    
  • Severe headache
    
  • Confusion
    
  • Signs of a life-threatening allergic reaction:
    
    • Feeling dizzy or faint
      
    • Trouble breathing or swallowing
      
    • Swelling of the tongue
      

• Rapid evolution of a rash with systemic symptoms can indicate a dermatologic emergency
  
• Treat rapidly with empiric antibiotics in patients with purpura and fever to cover for meningococcemia and RMSF.
  
• Treat rapidly with empiric antibiotics in patients with erythroderma, fever, and hypotension to cover toxic shock syndrome.
  
• Hyperpigmented scaly papules on the palms and soles require that secondary syphilis be ruled out.
  

• Brady WJ, DeBehnke D, Crosby DL. Dermatological emergencies.
  Am J Emerg Med
  . 1994;12(2):217–237.
  
• Browne BJ, Edwards B, Rogers RL. Dermatologic emergencies.
  Prim Care
  . 2006;33(3):685–695, vi.
  
• Freiman A, Borsuk D, Sasseville D. Dermatologic emergencies.
  CMAJ
  . 2005;173(11):1317–1319.
  
• Gropper CA. An approach to clinical dermatologic diagnosis based on morphologic reaction patterns.
  Clin Cornerstone
  . 2001;4(1):1–14.
  
• Usatine RP, Sandy N. Dermatologic emergencies.
  Am Fam Physician.
  2010;82(7):773–780.
  

See Also (Topic, Algorithm, Electronic Media Element)

Purpura

CODES

782.1 Rash and other nonspecific skin eruption

BASICS

• Lesion morphology:
  
  • Macule:
    
    • Localized nonpalpable changes in skin color
      
    • Purpura or petechiae (nonblanching with pressure)
      
  • Maculopapule:
    
    • Slightly elevated lesions with localized changes in skin
      
  • Papule:
    
    • Solid, elevated lesions <5 mm in diameter
      
    • Keratotic (rough-surfaced lesion)
      
    • Nonkeratotic (smooth lesion)
      
    • Palpable purpura (nonblanching with pressure)
      
  • Plaque:
    
    • Solid, elevated lesions >5 mm in diameter
      
    • Often results from a confluence of papules
      
  • Nodule:
    
    • Solid, elevated lesions extending deep into the dermis or SC tissue >5 mm in diameter
      
  • Wheal:
    
    • Circular, irregular lesions varying from red to pale
      
  • Vesicle:
    
    • Clear, fluid-filled lesions <5 mm in diameter
      
  • Bullae:
    
    • Clear, fluid-filled lesions >5 mm in diameter
      
  • Pustules:
    
    • Pus-filled lesions
      
• Secondary lesions:
  
  • Scales:
    
    • Thin plates of dried cornified epithelium partially separated from the epidermis
      
  • Lichenification:
    
    • Dried plaques resulting in skin furrowing
      
  • Erosion:
    
    • Moist surface uncovered by rupture of vesicles or bullae
      
  • Excoriation:
    
    • Linear loss of the skin due to trauma
      
  • Ulcer:
    
    • Deep loss of the skin involving the epidermis and a variable amount of the dermis and SC tissue
      
• Configuration:
  
  • Circles or arcs
    
  • Serpiginous (creeping or worm like)
    
  • Iris grouping (bull’s eye appearance)
    
  • Irregular grouping
    
  • Zosteriform grouping
    
  • Linear grouping
    
  • Retiform grouping
    
• The color of a lesion or the entire skin may be due to a number of substances:
  
  • Red or red-brown lesions result from oxyhemoglobin found in RBCs.
    
  • The macular erythematous lesions seen in viral exanthema usually represent dilated superficial cutaneous vessels.
    
  • Purpura and petechiae result from leakage of RBCs out of the vascular space.
    
  • Hypopigmentation or hyperpigmentation represent postinflammatory change from either increases or decreases in melanin production.
    
  • Depigmentation refers to the total loss of pigment secondary to autoimmune effect (vitiligo) or congenital disorders (albinism).
    
• Scales represent a proliferative disorder of epidermal cell turnover.
  

• Papulosquamous:
  
  • Infections:
    
    • Viral or bacterial
      
    • Rickettsial or fungal
      
  • Allergic reactions
    
  • Autoimmune disorders
    
• Purpura and petechiae:
  
  • Clotting or platelet disorder
    
  • Vascular fragility disease
    
  • Vasculitis
    
  • Overwhelming infection
    
• Vesicobullous:
  
  • Infection
    
  • Drug reaction
    
  • Autoimmune disorder
    
• Ulcer:
  
  • Infection
    
  • Vascular insufficiency
    

DIAGNOSIS