Dermatological Emergencies

Key concepts

  • You have to be able to describe the lesion(s) to diagnosis and manage it
  • Key steps: accurate history, physical examination, including lesions and distribution, and appropriate diagnostic tests.
  • Incision and drainage may be adequate therapy for simple abscesses**.
  • Tinea capitis requires 4 to 8 weeks of systemic antifungal treatment.
  • Onychomycosis requires long-term systemic treatment.
  • Newer nonsedating antihistamines are a useful alternative to older sedating ones to control pruritus and histamine-mediated rashes while allowing the patient to remain active.
  • Scabies infestations should be diagnosed clinically and treated expeditiously even without definitive proof of the infestation.
  • Medication reactions are common and may results from any medication, typically within 4 to 21 days after taking the medication.
  • Rashes that are associated with mucosal lesions, blisters, or desquamating skin are often caused by significant soft tissue infections, drug eruptions, or immune disorders.
  • Patients with Stevens-Johnson syndrome (<10% TBSA) and toxic epidermal necrolysis require inpatient treatment, preferably in a burn unit.
  • Cutaneous signs of systemic disease may include pruritus, urticaria, erythema multiforme, erythema nodosum, pyoderma gangrenosum, and others.
  • Physicians should be familiar with one or two topical steroid preparations of low, medium, and high potency and their appropriate therapeutic use.
    • Hydrocortisone 0.1% lotion – low/mid
    • Hydrocortisone valerate 0.2% ointment – mid
    • Betamethasone dipropionate 0.05% cream – high (more potent than beta.val)
  • Life-threatening conditions at risk for dehydration and infection require inpatient treatment – the rest should be managed as outpatients!

 

A B C Diaper Dermatitis E…

Diaper Dermatitis

The ABCDEs of Diaper Dermatitis Management [Klunk, 2014]

  • Air
    • Take the diaper off!
  • Barrier
    • First line therapies are typically non-medicated barrier creams.
    • Using simple petroleum product (ex, Vasoline) on top of the cream to prevent the barrier cream from sticking to the diaper.
  • Cleansing
    • Important to keep the area clean, but to use soaps with near-physiology pH levels.
    • Important to avoid scrubbing or over-cleaning.
  • Diaper
    • Frequent diaper changes (ie, every 2 hours) can help reduce time spent in a moist environment.
  • Education
    • Avoid potentially hazardous therapies:
      • Powders (ex, Talc, Baby Powder)
      • High-dose steroids (can become too potent in the occluded diaper region)

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Neonatal Dermatology

The Benign Conditions

  • Erythema toxicum
  • Transient neonatal pustular melanosis
  • Mongolian spot
  • Cutis marmorata
  • Congenital nevomelanocytic nevi
  • Acrocyanosis
  • Haemangioma
  • Salmon patch/stork bite
  • Port wine stain
  • Neonatal acne
  • Milia
  • Epstein pearls
  • Miliaria

Rashes you shouldn’t ignore

  • Epidermolysis bullosa
  • Congenital syphillis
  • Congenital rubella
  • Herpes simplex
  • Neonatal varicella
  • Aplasia cutis congenita
  • Neonatal lupus erythematosus
  • Incontinentia pigmenti

 

Eczema Management

  • A good emollient used twice per day should be recommended even in the absence of a current flare. Creams and emollients should be low in pH. As a general rule creams with no added plant or food substances should be recommend
  •  A class three steroid, like Advantan or Elocon (both have very good safety data) should be applied once to twice daily for as long as needed to the areas that are inflamed (with the exception of peri-oral or peri-orbital regions). Applying liberally and no longer sparingly is now the advice and we no longer use a week on, week off approach. As a general rule, if a good steroid is used twice a day for two weeks and the eczema hasn’t cleared, then something else is going on.