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CHAPTER 88 ■ DERMATOLOGIC URGENCIES AND EMERGENCIES ALISA McQUEEN, PETER A LIO GOALS OF EMERGENCY CARE The goals in treating dermatologic conditions are to recognize signs of systemic illness and complications such as secondary infection KEY POINTS The ability to describe a rash precisely and accurately will dramatically improve the likelihood of a correct diagnosis Key features of the history include duration of the rash (acute or chronic), initial distribution, extent of spread (generalized or localized), ill contacts (including sexual partners), and any associated systemic symptoms, including fever Key features of the physical examination include a careful systematic inspection of all mucocutaneous surfaces, with special attention paid to involvement of the oropharynx, palms and soles, extensor or flexor surfaces, scalp, and trunk RELATED CHAPTERS Medical, Surgical, and Trauma Emergencies Infectious Disease Emergencies: Chapter 94 Rheumatologic Emergencies: Chapter 101 Rashes and skin lesions are common presenting complaints An accurate diagnosis depends on a systematic approach that requires assessing the skin carefully and knowing dermatologic terminology, morphology, and differential diagnoses Although not always diagnostic, morphology and distribution of cutaneous lesions are important parts of categorizing and making a differential diagnosis, and at the very least can help exclude worrisome conditions when applied correctly Terminology is an important part of this process Descriptors can be divided into primary and secondary Primary descriptors include macules (flat 10 mm), nodules (solid lesion 0.5 to cm), pustules (elevation with pus), abscesses (elevated lesion >10 mm with purulent material), wheals (elevated lesion with local transient edema), vesicles (elevated lesion 10 mm containing fluid) Secondary descriptors include crust, scale, fissuring, erosions, ulceration, umbilication, excoriation, atrophy, lichenification, and scar In addition to these descriptions, it is also important to understand the distribution of the rash or lesion Distribution characteristics include localized, blaschkoid (following lines of embryologic development), widespread or generalized, and photodistributed (predilection for sun-exposed areas) Characterizing a rash or lesion using these descriptors narrows the differential diagnosis significantly The following sections of this chapter will divide skin changes by their primary descriptor and then will provide a framework for adding secondary characteristics to improve diagnosis PAPULES Papules can be quite varied and the following algorithm is used to help practitioners distinguish between some common papular lesions ( Fig 88.1 ) Papules With a Characteristic Appearance Many conditions can be diagnosed on sight For example, the experienced eye can easily distinguish milia from molluscum contagiosum (MC) and warts from the uncommon xanthoma Several clues make the process of separating these entities from one another easier such as color, distribution, and patient characteristics Milia Milia are 1- to 2-mm firm, white papules They are produced by retention of keratinous and sebaceous material in follicular openings Newborns often have milia on their face They frequently disappear by the age of month Milia can also arise from skin trauma, and can be seen in scars after burns and in healed wounds in patients with blistering disorders like epidermolysis bullosa Persistent milia may be a manifestation of the oral–facial–digital syndrome, hereditary hypotrichosis (Marie Unna type), and certain rare ectodermal dysplasias Because lesions that are not associated with syndromes often disappear spontaneously, reassurance is generally warranted, though lesions may be easily removed by carefully nicking the surface and expressing the keratin This can be a simultaneously diagnostic and therapeutic procedure Molluscum Contagiosum The lesion, caused by the molluscipoxvirus , a member of the pox virus subfamily, is a papule with a white, umbilicated center ( Fig 88.2 ) It occurs at any age during childhood, but is more common among swimmers and wrestlers Patients with atopic eczema are especially susceptible Most lesions resolve in to months, but some may persist for years Spread is by autoinoculation FIGURE 88.1 Approach to diagnosis of papular lesions Lesions can be single or numerous and favor intertriginous areas such as the groin They are usually to mm in diameter, but several can coalesce and form larger lesions They may become inflamed, which may herald a spontaneous disappearance Often when inflamed, they look “infected” but culture is usually negative At times, an eczematous reaction occurs around the lesions Since spontaneous resolution is common, treatment, if elected, should be gentle Application of 0.1% tretinoin cream one to two times daily may induce enough inflammation to hasten the host’s immune response or cause extrusion of the central core, but caution should be observed since tretinoin may exacerbate secondary eczematization around molluscum lesions Options for surgical excision are available but are not appropriate emergency department procedures FIGURE 88.2 Child with lesion of molluscum Warts Warts affect 7% to 10% of the population and are one of the most common dermatologic problems encountered in pediatrics The peak incidence is during adolescence Sixty-five percent of common warts disappear spontaneously within years, and 40% of plantar warts disappear within months in prepubertal children However, immunosuppressed patients may experience extensive spread of the lesions The common wart resembles a tiny cauliflower Lesions disrupt the natural skin lines and may also manifest with small black dots, representing thrombosed capillaries The shape of the wart varies with its location on the skin They may be long and slender (filiform) on the face and neck or flat (verruca plana) on the face, arms, and knees When located on the soles, they are called plantar warts , and when in the anogenital area, they are referred to as condyloma acuminata  ... eczematization around molluscum lesions Options for surgical excision are available but are not appropriate emergency department procedures FIGURE 88.2 Child with lesion of molluscum Warts Warts affect 7%... 7% to 10% of the population and are one of the most common dermatologic problems encountered in pediatrics The peak incidence is during adolescence Sixty-five percent of common warts disappear