Abstract
Simple skin conditions are often evaluated in urgent care settings. This chapter gives an overview of the most common skin conditions and rashes that present to urgent care centers.
Keywords
abscess, burns, cellulitis, contact dermatitis, erysipelas, erythema migrans, folliculitis, impetigo, pityriasis rosea, poison ivy, scabies, shingles, tick removal, tinea, warts
Contact Dermatitis
1
Describe allergic contact dermatitis
Allergic contact dermatitis ( Fig. 9.1 ) is a very itchy eczematous rash with varying sizes of papules, vesicles, and bullae. It affects skin exposure sites and is associated with erythema and edema that can be oozing or crusting depending on the timing of presentation. These are immune-mediated, delayed hypersensitivity reactions and typically present 1–2 days after the exposure.
2
What are some common precipitants of an allergic contact dermatitis?
Cosmetics, plants (poison ivy), detergents, soaps, lotions, antibiotic ointments and creams, metals, plastics, latex, rubber, various chemicals, tapes.
3
Describe the treatment for an allergic contact dermatitis.
Avoidance or removal of identified allergen. Clean and wash skin with hypoallergenic soap. Symptom management with cold compresses and antihistamines. It is generally accepted that the mainstay of treatment is topical steroids for mild reactions and systemic steroids for severe reactions. It is key to appreciate any secondary infection and treat with appropriate antibiotics; however, antibiotics are only indicated if an infection is present.
4
What is a common cause of treatment failure in contact dermatitis?
Short courses of steroids. Systemic corticosteroids such as prednisone or triamcinolone should usually consist of a higher dose for at least 5 days and then a prolonged taper in an effort to prevent rebound dermatitis. It is not necessary to provide both topical and systemic steroids. It should be noted that very potent topical steroids should be avoided for use on the face and genitals and fluorinated corticosteroids should be limited to 10–14 days, specifically on the face.
5
Poison ivy, oak, and sumac all cause forms of allergic contact dermatitis. What is the typical duration of symptoms?
Typical duration is 2 weeks untreated. If being treated with topical or oral steroids, duration may be shorter; however, treatment usually needs to be continued for 2 more weeks after resolution of symptoms or the dermatitis will reappear.
6
A patient with small linear vesicles after exposure to poison ivy presents with severe itching that does not resolve with Benadryl cream or tablets. Why?
This is a delayed immune-mediated reaction and not related to histamine release. Because of this, antihistamines may not provide much relief of symptoms. Initial treatment should include cool compresses and tepid baths with oatmeal colloid or baking soda. Small areas of involvement can be treated with topical steroids. Severe involvement or involvement of face, eyes, and gentitalia may require oral steroids. This needs to be over a 2- to 3-week period or the patient will have rebound dermatitis.
7
How can you tell the difference between allergic contact dermatitis and irritant contact dermatitis?
In many cases, it is impossible to tell the difference by appearance, although you may be able to tell a difference with key parts of the history and timing of onset. Irritant contact dermatitis does not require previous sensitization and is not a delayed immune reaction, but it is a skin barrier disruption and may present within a few hours of exposure to an irritant. Many times there is repetitive exposure leading to skin breakdown.
8
List some common irritants for irritant contact dermatitis and describe initial treatment
Anything that can cause a skin barrier disruption can lead to irritant contact dermatitis (ICD). This includes (but is not limited to) water, soaps, detergents, or repetitive trauma. Initial treatment is avoidance of the irritant and frequent moisturization of the skin. Since this is a barrier breakdown process and not related to an immune-mediated response, steroids are not always indicated. Topical steroids may be used to help with local inflammation, but only if necessary.
Cutaneous Abscesses
9
What is the most accepted management for a simple cutaneous abscess?
Simple abscess management is typically a bedside incision and drainage. Incision and drainage can be very painful and it is difficult to control pain and because the larger abscesses may require sedation for management.
10
Why do people presenting with a cutaneous abscess think they have been bitten by a spider?
Many abscesses will present with a central area of skin thinning with a dark necrotic center that does look similar to the erythematous lesion of a spider bite. A careful history can determine the patient’s risk for a spider bite, although a confirmed bite typically requires a captured or recovered spider. If a bite is suspected, treatment is generally supportive care with immobilization, elevation, and cold compresses (avoid heat). Early excision or debridement is not recommended but should be delayed until the wound has stabilized. Other treatment strategies should be based on the type of spider involved.
11
Should all cutaneous abscesses be incised and drained?
In general, the standard treatment of an abscess is to drain it. There are times when a patient may present early in the formation of a simple abscess and the cavity may not be identified or yet present. For these patients, antibiotics with application of moist warm compresses and close follow-up in 24 hours is appropriate. The use of bedside ultrasound or attempted needle aspiration using aseptic technique to identify the abscess cavity is appropriate in these settings. Small pustules do not need large incisions but can be unroofed with an 18-gauge needle with aseptic technique and many times do not require any anesthesia.
12
After incision and drainage of an abscess, should the cavity be packed with sterile or iodoform gauze?
Recent literature has not shown a benefit to wound packing for simple cutaneous abscesses. In the past, it was taught that all drained abscesses should receive loose packing to allow for healing from the “inside out” and debridement of the wound bed with removal of packing. Unfortunately packing is difficult to keep in place and is associated with increased pain. It is now accepted that simple abscesses (not immunocompromised, smaller abscess size, nondiabetic patient) can be left unpacked. All drained abscesses should receive close follow-up as well as daily wound care with soap and water. Also, new commercially available products can be used to help keep an incision open for drainage, and new techniques can be used for larger abscess sizes (loop drainage).
13
Who should receive antibiotics after incision and drainage?
This is also a controversial question and has been changing over recent years. Based on recent literature, incision and drainage alone is adequate for management of simple abscesses (small size, nondiabetic, immunocompetent patients without surrounding cellulitis or systemic symptoms). When antibiotics are indicated they should be targeted to cover community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) due to its increased prevalence. The provider should incorporate local antibiotic resistance patterns as well as stay current with the Infectious Diseases Society of America (IDSA) guidelines on management of skin and soft tissue infections.
14
Who would be considered higher risk or described as a complicated case in the management of a cutaneous abscess?
Immunocompromised patients, diabetic patients, large abscess size (>5 cm), patients who present toxic and febrile, significant associated cellulitis, infections on the hands or face.
15
What is the difference between a folliculitis, a furuncle, and a carbuncle?
Folliculitis ( Fig. 9.2 ), a superficial infection of a hair follicle, can initially be treated with daily cleansing with soap and water, warm compresses, and topical mupirocin ointment. A furuncle is an extension of a folliculitis to subcutaneous tissue. Many times these require CA-MRSA antimicrobials and abscess drainage if indicated. A carbuncle represents interconnected furuncles, which are essentially multiseptate abscesses that require drainage with blunt dissection and antibiotic treatment.
Cellulitis, Erysipelas, Impetigo
16
What is the difference between erysipelas and cellulitis?
Both are soft tissue skin infections; however, cellulitis involves the deeper subcutaneous connective tissue. Erysipelas is typically bright red with very distinct, demarcated borders ( Fig. 9.3 ). Cellulitis is also erythematous and red but has indistinctive borders and is more associated with systemic symptoms ( Fig. 9.4 ). Both are warm to touch and tender upon palpation.
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