Peds Dermatology

Acne vulgaris 

• Path:
  • Sebaceous glands enlarge with adrenarche (the prepubertal period in which levels of DHEA-S rise) and sebum production increases
    
  • Sebum provides a great growth medium for P. acnes – an anaerobic bacteria usually in normal skin flora.
    
  • P acnes produces enzymes that degrade the follicular wall and trigger a humoral and cell-mediated immune response
•  4 main pathogenetic factors:
  • Inflammation of pilosebaceous units
    
  • Increased sebum production
    
  • Follicular obstruction from hyperkeratinization
    
  • Propionibacterium acnes bacteria (or Cutibacterium acnes)
    
  • These 4 factors stimulate innate and cellular immune responses.
  • There are also additional influences like genetics and diet.
• Open vs closed comedones:
  • Open comedones = blackhead
    
    • -Densely packed keratinocytes, oxidized lipids, and melanin
      
  • Closed comedones = whitehead
    
    • – Accumulation of sebum and keratinous material
• Persistent acne and hirsutism:
  • Red flag for hyperandrogenism (PCOS, tumors)
• Treatment:
  • Retinoid – Tretinoin
    
  • Benzoyl peroxide, salicylic acid
    
  • Spironolactone (aldosterone antagonist)
    
  • Topical antibiotics (erythro or clinda) vs oral abx (minocycline, doxy, erythro)

Roshu Bangal, CC BY-SA 4.0, via Wikimedia Commons
BedrockPerson, CC BY-SA 4.0, via Wikimedia Commons

Anaphylaxis

• Path:
  • Most severe form of immediate type I hypersensitivity.
• Presentation:
  • Pruritis, urticaria, angioedema, laryngeal edema, wheezing, nausea, vomiting, tachycardia, sense of impending doom, shock.

Androgenetic alopecia

• Presentation:
  • It can be a presenting symptom in PCOS.
• Diagnosis:
  • Check free and total testosterone in females, if elevated could be a signal of PCOS.

Angioedema

• Path:
  • Swelling of the deeper dermis. Results from mast cell activation in the subcutaneous tissues or by non-mast cell mechanisms.
    
  • IgE mediated drug reaction

James Heilman, MD, CC BY-SA 3.0, via Wikimedia Commons

Atopic dermatitis (Eczema)

• Path:
  • Superficial inflammatory response of the epidermis. T cell-mediated immune activation and increased IgE production
• Triggers:
  • heat, perspiration, allergens, contact irritants (wool, nickel, foods)
• Presentation:
  • Tiny pruritic erythematous edematous ill-defined blisters that dry and crust over. Most common on extensors and in the face in infants (flexor surfaces and antecubital folds in adults)
• Allergic triad:
  • Eczema, allergic rhinitis, asthma
• Treatment:
  • 1st: Topical steroid (often OTC hydrocortisone not enough)
    
  • 2nd: Topical anti-inflammatories (Calcineurin inhibitors)
    
  • The non-sedating antihistamines approved for children, loratadine, fexofenadine, and cetirizine may be effective.
  • Emollient ointment (glycerol, petroleum jelly) + ceramide moisturizer (Eucerin)
    
  • Topical corticosteroids (hydrocortisone, fluticasone, betamethasone) and antihistamines
    
  • Topical immune modulators (calcineurin inhibitors = Tacrolimus)

James Heilman, MD, CC BY-SA 3.0, via Wikimedia Commons

Madhero88, CC BY-SA 3.0, via Wikimedia Commons

Burns

• Formula:
  • Parkland formula. Lactated ringers at 4ml x kg x BSA burn
    – Half over the first 8 hours, the rest of the next 16 hours
• Body surface area:
  • 18% on the head, 14% each extremity
    
  • Otherwise same as the adult rule of 9’s
    
  • (9% each arm, 18% front of back, 18% back of back)

The original uploader was K. Aainsqatsi at English Wikipedia.(Original text: K. Aainsqatsi), CC BY-SA 3.0, via Wikimedia Commons

Congenital syphilis

• Presentation:
  • Copper-colored scaly macules and papules or moist erosions. Lesions are present at or after birth and seen in the diaper area and/or around the mouth and nose.
  • Condyloma lata – perianal papular lesions
    skin lesions contain spirochetes and are highly infectious
  • Other manifestations: symmetric desquamation of palms and soles, anemia, hepatosplenomegaly, jaundice, and changes of the long bones.
• Diagnosis:
  • Serology or dark field microscopy

Contact dermatitis

• Path:
  • Type IV hypersensitivity reaction to agents that come in contact with the skin
• Presentation:
  • with inflammatory papules, vesicles, weeping or crusting.
  • Usually, intense pruritis, prominent scale, and lesions fail to improve with antibiotic therapy
  • Burning sensation if it irritant contact dermatitis
  • Eczematous (irritant) or vesicular (allergic)

Poison Ivy

Alborz Fallah, CC BY-SA 3.0, via Wikimedia Commons

Dermatophyte Infections

• Etiology:
  • – aka tinea infections
    
  • – dermatophytes only live in tissues with keratin (skin, nails, and hair)
• Dermatophytes:
  • – Trichophyton (most common)
  • – Microsporum: Unlike Trichophyton, Microsporum is characterized by a bright green fluorescence when the lesion is observed under Wood’s ultraviolet (UV) lamp.
  • – Epidermophyton
• Diagnosis:
  • – clinical
    
  • – best initial: KOH showing hyphae
    
  • – most accurate: fungal culture
• Management:
  • – start with topical antifungals; escalate to oral if infection is widespread or unresponsive to topicals
    
  • – systemic antifungal as first line for:
    
    • ++ Tinea capitis
      
    • ++ immunocompromised patients
  • Medication:
    • – Terbinafine and Itraconazole.: cheap and very effective
    • – Fluconazole: weekly dosage, less effective and more expensive
    • – Ketoconazole and Griseofulvin: lengthy treatment time, high recurrent, required labs monitoring

Diaper dermatitis

• Path:
  • Most common skin eruption in infants and toddlers.
  • Peak age between 9-12 months.
  • Altered stratum corneum from excessive moisture, friction, increased pH and high enzyme activity
  • Fecal bacteria produce enzyme urease which interacts with urine to increase the pH.
    • This activates protease and lipase which directly irritate and damage the skin.
  • SKIN FOLDS ARE SPARED
• Secondary Infections:
  • If it is left untreated for more than 3 days, secondary infection with
    
  • 1) Candida (beefy read plaques, satellite papules, and superficial pustules. Confirmed with KOH) GOES IN THE SKIN FOLDS
    
  • 2) Streptococcal perianal dermatitis (bright red sharply demarcated perianal or perineal erythema. Sometimes perirectal fissures, blood-streaked stools, pruritis, and pain with defecation) Treat with Abx.
  • 3) Impetigo (secondary infection with S. aureus and less frequently S. pyogenes. 1-2mm fragile pustules and honey-colored crust. Confirm with gram stain and bacterial culture)
    
  • 4) Herpes simplex virus infection – (Vesicular, papular, or pustular lesions in the diaper area. Possible manifestation of child abuse) Diagnose with viral culture, PCR, Tzanck preparation
• Deficiencies:
  • acrodermatitis enteropathica, biotin deficiency, cystic fibrosis
• Risk Factor:
  • Diarrhea or chronic stooling
    
  • Breastfed have a lower incidence
    
  • Recent use of broad-spectrum antibiotics may predispose infants to develop
• Differential diagnosis:
  • 1) Seborrheic dermatitis – erythematous papules and plaques with greasy yellow scale more prominent in skin folds. Usually involvement of head (cradle cap). Responds to low-potency corticosteroids or topical antifungal preparations
  • 2) Atopic dermatitis – usually spares diaper area due to the moisture. May have excoriations due to scratching. usually history of family atopy
  • 3) Allergic contact dermatitis
  • 4) Psoriasis – sharply demarcated erythematous scaly papules and plaques.
  • 5) Scabies – acute, widespread, pruritic dermatitis
• Treatment:
  • Frequent diaper changes every 2 hours or when soiled. Open-air exposure. Topical zinc oxide or petroleum jelly. 1% hydrocortisone (use for <2 weeks).
    
  • May need topical antibiotics (mupirocin applied twice a day for 5-7 days to treat staphylococcal)
  • Candida Tx: Nystatin, clotrimazole, miconazole, ketoconazole.

Erythema infectiosum (5ths disease)

• Path:
  • Parvovirus B19 spread by respiratory droplets. 4-14 day incubation period
    
• Presentation:
  • Prodrome of coryza, fever, headache, diarrhea
  • -> slapped cheek rash with circumoral pallor 2-4 days
  • -> lacy reticular rash (blanching erythema) on extremities that spares palms and soles.
  • Resolves in 2-3 weeks
    
• Complications:
  • Arthropathy (in older kids and adults), an aplastic crisis with sickle cell disease, pure red blood cell aplasia in immunocompromised individuals
    
  • Fetal infection can lead to non-immune hydrops fetalis, intrauterine fetal death or miscarriage** KEEP PREGNANT PEOPLE AWAY!
• Treatment:
  • supportive

Erythema multiforme

• Presentation:
  • Acute immune-mediated condition characterized by the appearance of distinctive target-like lesions on the skin.
  • Papules evolve into pathognomonic target lesions that appear in a 72 hour period and begin on the extremities.
  • They are there for 7 days and then begin to heal.
  • Often also erosions or bullae involving oral, genital, and/or ocular mucosae.
    • If not mucosal involvement it is EM minor.
    • If there is, it is an EM major.
• Cause:
  • Usually induced by infection with herpes simplex virus being the most frequent precipitator.
  • Also EBV and histoplasmosis.
    
  • *Mycoplasma pneumonia is another important cause, especially in children.
    
  • Usually self-limited and resolves within weeks
• EM Minor:
  • – target lesion distributed equally, no mucosal membrane lesions
    
• EM Major:
  • – target lesions + 1 mucous membrane (oral, genital, ocular mucosa)
    
  • Target lesion = dull “dusty violet” red, purpuric macule/vesicle or bullae in the center surrounded by a pale edematous rim and peripheral red halo
• Treatment:
  • D/c the drug (sulfa, B-lactam, phenytoin, phenobarbital)
    
  • Antihistamines, analgesics, skincare
    
  • Steroid/lidocaine/diphenhydramine mouthwash for oral lesion

Hand foot and mouth disease

• Path:
  • Coxsackie A virus. Spread fecal orally and orally.
  • Usually occur in those less than 5 and in summer and fall
• Presentation:
  • Clinical syndrome characterized by an oral enanthem and a macular, maculopapular, or vesicular rash on an erythematous base of the hands and feet
  • *Rash generally starts out as macules that progress to vesicles surrounded by erythema. Vesicles rupture and form ulcers with grey-yellow base
  • Non-pruritic and generally not painful. Lesions resolve in 3-4 days.
  • Symptoms include mild fever, URI symptoms, decrease appetite starting 3-5 days post-exposure
• Complications:
  • Decreased oral intake
  • Rhombencephalitis
    
  • Acute flacicid paralysis
    
  • Aseptic meningitis
    
  • Myocarditis
    
  • *NO vaccine

HPV

• Strains:
  • 16 and 18 cause approximately 70% of all cervical cancers
    
  • 31, 33, 45, 52, 58 cause 20%
    
  • 6 and 11 cause approximately 90% of anogenital warts
• Gardasil vaccine:
  • Protects against 70% HPV strains. In united states the 9 valent vaccine is available
  • Covers 6, 11, 16, 18, 31, 33, 45, 52, 58.
  • ACIP (Advisory Committee on Immunization Practices) recommends for females at 11 and 12 years and can start at age 9. Catch up at 26 years
  • Males age 11 and 12 can start at age 9. Catch up at 21.
  • Older than 26 years is the increased likelihood of prior exposure to HPV vaccine types with age, which reduces the potential individual benefit and thus the cost-effectiveness of HPV vaccination

Impetigo

• Path:
  • Common staphylococcal or streptococcal skin infection with erosions, vesicles, and yellow crusts
    
  • MC S. aureus, second most common is GABHS
• Diagnosis:
  • Gram stain and bacterial culture – confirmation
• Treatment:
  • Bactroban 2% ointment (Mupirocin)x10 days or Bacitracin
    
  • For extensive disease – Keflex, Clinda, Dicloxacillin, Azithromycin

Langerhans cell histiocytosis

• Etiology:
  • heme/oncology condition.
  • Severe diaper dermatitis.
  • Cutaneous lesions have red/orange or yellow/brown scaly papules, erosions, or petechiae.
  • It can resemble seborrheic dermatitis but the color of lesions and the presence of petechiae differentiate.
  • They also have bone lesions, lymphadenopathy, hepatosplenomegaly, and anemia.
• Diagnosis:
  • Confirm with a skin biopsy.

Lice (Pediculosis)

• Presentation:
  • Itching, papular urticaria, visualization of live lice or nits
    
• Treatment:
  • Permetherin 1% cream
    
  • Examine household and close contacts, wash bedding
    
  • Place toys in airtight bag x14 days

Lichen planus

• Presentation:
  • Symmetric eruption of flat-topped erythematous or violaceous papules resembling lichen planus on the trunk and extremities
  • It can affect the skin (flexor surfaces), oral cavity, genitalia, or scalp.
  • 4 P’s
    • Pruritic
    • Purple
    • Polygonal
    • Papules or plaques
  • Fine white lines – Wickham’s striae
  • Koebner phenomenon – development of skin lesions at the site of trauma.
• Cause:
  • Ace inhibitors, ranitidine, chloroquine/hydroxychloroquine (antimalarial drugs), antipsychotics/anticonvulsants, thiazide diuretics, sulfonylureas, gold salts, PPI omeprazole
• Locations:
  • Extremities and volar/flexor surface of the wrists
    
  • Oral lichen planus – increased risk for oral SCC cancer
• Treatment:
  • 1st line = antihistamines, steroid ointment
    
  • 2nd line = systemic steroids, UVB therapy
    
  • Topical corticosteroids/Mild on the face
    
  • If localized on trunk and extremities, use high potency (0.05% betamethasone dipropionate or 0.05% florasone diacetate)

Miliaria

• Path:
  • Caused by blockage/occlusion of sweat ducts.
• Presentation:
  • More common in warm climates or febrile overdressed infants
    
  • Often affects the forehead, neck, and upper trunk. Concentrated in areas where sweat can develop
• 3 subtypes:
  • 1) Miliary crystallina – 1-2mm vesicles of clear fluid without surrounding erythema
    
  • 2) Miliaria rubra – heat rash. Small erythematous papules and vesicles
    
  • 3) Miliaria pustolosa – variant of miliaria rubra with severe inflammatory response
• Treatment:
  • Usually, resolve in a few days. May be mild desquamation that can last hours to days. Treat by avoiding overheating

Molluscum contagiosum

• Path:
  • Viral infection. Benign from the Poxvirus family.
    
  • Highly contagious (skin to skin, fomites)
    
• Presentation:
  • Dome shaped flesh colored/pearly white waxy papules with central umbilication
    
  • Curd like material expressed from the center if squeezed
    
  • Usually, resolve 3-6 months, can use imiquimod or podophyllin

Mumps

• Path:
  • Paramyxovirus spread by respiratory droplets, 12-14 days incubation period
    
• Presentation:
  • Symptoms of low-grade fever, myalgias, headache, and painful parotid gland swelling
• Complications:
  • Orchitis, encephalitis, aseptic meningitis, deafness, pancreatitis
• Treatment:
  • supportive
  • Anti-inflammatories
  • MMR vaccine

Neonatal acne

• Presentation:
  • Inflammatory papules and pustules located mainly on the forehead, nose, and cheeks. No true comedones (blackheads or whiteheads)
  • Usually a result of inflammatory reaction to Pityrosporum (Malassezia) species
  • Presents around 2nd and 3rd week of life and resolves around 6-12 months of age.
• Treatment:
  • * Self-limited. Some patients may benefit from topical antifungals.

Pediculosis

Perioral dermatitis

• Presentation:
  • Multiple small inflammatory papules around the mouth, nose, or eyes
    
  • Irritants and topical corticosteroids may contribute to this disorder.
    
  • Usually spares the vermillion border and no comedones
• Treatment:
  • Topical anti-inflammatory agents and topical or systemic antibiotics.
  • Usually, resolve within in few months with discontinuation of the topical corticosteroid.
  • Appearance can be disturbing so oral tetracycline, topical pimecrolimus, topical erythromycin, and topical metronidazole
  • Systemic antibiotics – oral tetracyclines (but not under age 9 due to potential for adverse effects on teeth and bone.
    • Do erythromycin if can’t tolerate tetracycline)

Pigmented Lesions

Pityriasis rosea

• Presentation:
  • Self-limited.
  • Slightly inflammatory, oval, papulosquamous lesions on the trunk and proximal areas of the extremities.
  • PRURITIC
  • Maybe a manifestation of human herpesvirus 7
  • Begins with herald patch in 50-90% of cases. Usually round or oval, sharply delimited, pink or salmon-colored on chest/neck/back.
  • This lesion becomes scaly and begins to clear centrally leaving the free edge of cigarette paper-like scale directed toward the center (collarette of scale)
• Spread:
  • Centrifugally (from top to bottom)
    
  • Usually resolves in 4-6 weeks
    
  • In children can be “inverse” affecting face and extremities and sparing the trunk.
• Diagnosis:
  • Usually no laboratory abnormalities.
  • May need to do KOH to detect for dermatophyte hyphae and see if its tinea or do serologic testing to rule out syphilis in sexually active
• Treatment:
  • Will resolve in 2-3 months.
  • Topical steroids can help control the itching.
    • Can apply 2-3 times daily for 2-3 weeks.
  • Long term use avoided because of corticosteroid-induced skin atrophy
    
  • Can also try PO antihistamines, moisturizers, oatmeal baths, UVB light

Rubeola (measles)

• Path:
  • Paramyxovirus spread by respiratory droplets, 10-12 day incubation period
• Presentation:
  • URI prodrome of high fever, cough, coryza, conjunctivitis, koplik spots (48 hours before the rash) (4 C’s) followed by exanthem
  • Maculopapular (morbilliform) brick-red rash on face then lesions coalesce and spread to extremities
  • Rash lasts 7 days and fever concurrent with rash
• Complications:
  • Otitis media, pneumonia, diarrhea, encephalitis
• Treatment:
  • Supportive, anti-inflammatory, isolate for 1 week after rash onset MMR vaccine
     

Roseola

• Path:
  • 6th disease. Caused by HHV 6 usually. Sometimes HHV 7, coxsackieviruses A and B.
• Presentation:
  • 90% of cases in those under 2 years old. Most between 7 and 13 months.
  • High fever for 3-5 days then fever decrease coincides with a rash
  • Rose pink maculopapular blanchable rash on trunk/back -> face
  • *ONLY viral exanthem that starts on the trunk and spreads to the face
  • Malaise, palpebral conjunctivitis, edematous eyelids, inflammation of the tympanic membranes, uvulopalatoglossal junctional macules or ulcers (Nagayama spots), upper or lower respiratory symptoms, vomiting, diarrhea, lymphadenopathy
  • High fever and bulging fontanelle usually results in evaluation for possible meningitis
  • Sterile pyuria – may be diagnosed with UTI
• Complications: 
  • Seizures, aseptic meningitis, encephalitis, and thrombocytopenic purpura.
  • No vaccine, infection results in immunity
• Transmission:
  • Spread by respiratory droplets, 10 day incubation period.
• Treatment:
  • – supportive, anti-inflammatories

Rubella (German measles)

• Path:
  • Togavirus (RNA virus) spread by respiratory droplets, 2-3 week incubation period.
  • Peaks in winter and early spring.
  • Rash lasts 3 days (simultaneous with the fever)
• Presentation:
  • Low fever, cough, anorexia, lymphadenopathy. May also have photosensitivity and joint pains
  • Blueberry muffin rash (pink, light-red spotted maculopapular rash on the face –> extremities) Pinpoint maculopapules.
  • More rapid spread than Rubeola and rash does not darken or coalesce
  • Other:
    • Mild nonexudative conjunctivitis and exanthem/petechiae of soft palate (Forchheimer spots) also may be observed, and occasionally acute thyroiditis develops
• Notes:
  • TERATOGENIC!!!! Part of TORCH.
• Congenital rubella infection:
  • Sensorineural deafness, cataracts/glaucoma, pigmentary retinopathy, TTP, mental retardation, heart issues
  • Highest risk of maternal to fetal transmission occurs in the first 10 weeks of gestation
    • -Cardiac and eye problems usually develop before 8 weeks
    • -Hearing loss may develop up to 18 weeks
    • *Congenital defects unlikely if maternal infection occurs after 18 to 20 weeks gestation
• Treatment:
  • Supportive, anti-inflammatories
    
  • Generally are no complications

Scabies (Sarcopetes scabei)

• Path:
  • Female mites burrow into the skin and la eggs.
• Presentation:
  • Intensely pruritic, especially at night.
  • Red papules and linear burrows common in intertriginous zones.
  • Usually spare neck/face
  • Symptoms last 4-6 weeks and usually a clinical diagnosis but can do a skin scraping
• Treatment:
  • Permethrin 5% cream applied to all areas of the body from neck down and washed off after 8-14 hours.
    • 2 applications separated by 1 week.
      
  • OR oral ivermectin
    • – given as single 200mcg/kg dose repeated after 1-2 weeks

Tinea

• Path:
  • Dermatophyte infection. Inflammatory pustules. Almost always have an asymmetric distribution
• Diagnosis:
  • KOH prep – confirmatory
• Treatment:
  • Terbinafine (Lamisil) for 1-2 weeks
    
  • Ketoconazole x2 weeks
    
  • Griseofulvin PO for tinea capitis and unguium (avoid steroids and nystatin)

Tinea versicolor

• Path:
  • Hypopigmented or erythematous macules with fine-scale.
• Presentation:
  • No itch, predominately on the trunk
    
• Diagnosis:
  • KOH shows spaghetti and meatball pattern with short hyphae and yeast
    
• Treatment:
  • Fluconazole (Diflucan)
    
  • Ketoconazole
    
  • Selenium sulfide

Urticaria

• Path:
  • Type I/IgE mediated.
    
  • mast cells release histamine -> vasodilation of venules -> edema of dermis and subq tissue
• Triggers:
  • antigen from foods, meds, infection, insect bites, drugs, environment
• Presentation:
  • Blanchable, edematous pink papules/wheals/plaques.
    
  • Darier’s sign = localized urticaria appearing where the skin is rubbed
    
  • Angioedema – a painless deeper form of urticaria affecting lips/tongues/eyelids/hands/feet
• Treatment:
  • PO antihistamine, H2 blockers, corticosteroids, eliminate precipitants

James Heilman, MD, CC BY-SA 3.0, via Wikimedia Commons
James Heilman, MD, CC BY-SA 4.0, via Wikimedia Commons

Verrucae

Viral Exanthems

Drug eruptions

• Presentation:
  • Exanthems, morbilliform, and macular/papular eruptions.
• 5 types of drug eruptions:
  • 1) Type I (IgE mediated) – immediate urticaria/angioedema
    
  • 2) Type II (Ab-mediated) – cytotoxic
  • 3) Type III (Immune Ab-antigen complex) – drug-mediated vasculitis and serum sickness
    
  • 4) Type IV (delayed cell-mediated) – erythema multiforme
    
  • 5) Nonimmunologic – cutaneous reactions due to genetic incapability to detoxify certain drugs (anticonvulsants, sulfonamides)

DRESS

• Path:
  • Drug reaction with eosinophilia and systemic symptoms
    
• Presentation
  
  • Fever (100-104)
    
  • Malaise
    
  • Lymphadenopathy
    
  • Skin eruptions
    
  • begins 2-6 weeks after initiation of offending meds.
  • Usually aromatic antiepileptic agents (carbamazepine, lamotrigine) allopurinol, or sulfonamides.

SDRIFE

• Presentation:
  • Symmetrical drug-related intertriginous and flexural exanthema.
  • Occurs a few hours to a few days after the administration of the offending drug.
  • Usually appears as demarcated V-shaped erythema in gluteal/perigenital area and involvement of at least 1 other flexural or intertriginous fold
• Treatment:
  • Amoxicillin, ceftriaxone, penicillin, clindamycin, and erythromycin involved in 50% of cases.

SJS and TEN

• Presentation:
  • SJS is less than 10% of body
    
  • TEN more than 30% of body
• Common drugs associated with SJS/TEN:
  • Allopurinol
    
  • Carbamazepine
    
  • Etoricoxib
    
  • Lamotrigine
    
  • Meloxicam
    
  • Nevirapine
    
  • Oxcarbazepine
    
  • Phenobarbital
    
  • Phenytoin
    
  • Piroxicam
    
  • Sulfadiazene/sulfadoxine/sulfamethoxazole/sulfasalazine
    
  • * seen especially with sulfa and anticonvulsant drugs

Stevens-Johnson syndrome

• Path:
  • Epidermal necrosis and sloughing of the mucous membranes of the skin.
• Diagnosis:
  • Immediate in-hospital evaluation for diagnosis and confirmation and evaluation of the severity
• Treatment:
  • referral to burn unit/ICU/dermatology, and initiation of supportive treatment

Toxic epidermal necrolysis

• Presentation:
  • Fever and extensive necrosis and detachment of the epidermis. >30% of the body and oral membranes also usually involved.
  • SCORTEN score (Score of Toxic epidermal necrosis):
    • Get a point for the following:
      
      • Age >40
        
      • Malignancy – yes
        
      • Body surface area detached >10%
        
      • Tachycardia >120/min
        
      • Serum urea >10
        
      • Serum glucose >14
        
      • Serum bicarbonate <20
      • If >2 should be transferred to ICU, burn unit, or specialized dermatology unit
• Diagnosis:
  • Immediate in-hospital evaluation for diagnosis and confirmation and evaluation of the severity
• Treatment:
  • referral to burn unit/ICU/dermatology, and initiation of supportive treatment

Rashes that affect palms and soles

• Coxsackie (HFM)
  
• RMSF
  
• Syphilis (secondary)
  
• Janeway lesions
  
• Kawasaki
  
• Measles
  
• TSS
  
• Reactive arthritis
  
• Meningococcemia