Skin Problems

© Springer International Publishing Switzerland 2017
Bobby Desai and Alpa Desai (eds.)Primary Care for Emergency Physicians10.1007/978-3-319-44360-7_24

24. Skin Problems

Gail A. Knight  and Cheri N. Adgerson 

Emergency Medicine, UF Health Shands Hospital, Gainesville, FL 32610, USA

Dermatology, UF Health Shands Hospital, Gainesville, FL 32606, USA



Gail A. Knight (Corresponding author)


Cheri N. Adgerson

AtopyDermatitisParasitic infectionsScabiesBedbugsLiceFungal infectionsMelismaErythema nodosumAcne

24.1 Introduction

In 2010, 4.2 % of all emergency department (ED) visits were for rash or itching of which the differential diagnosis can be quite broad. Diagnosis and management are primarily based on history and physical exam. Laboratory and imaging workup can oftentimes be quite limited particularly in the ED as the diagnostic gold standard for most rashes or rashes of unclear etiology is skin biopsy. Indeed, this is a malady that is not going to be solved by the shotgun approach.

24.2 Differential Diagnosis

The differential diagnosis of skin conditions which may present to the emergency department is quite broad and may be stratified. This text will serve as a primer in more common acute and chronic conditions as well as the initiation of treatment from a primary care standpoint.

24.2.1 Dry Skin (Xerosis)

  • Presentation

    • Intense itching particularly of anterolateral legs (shins) and can range in severity, affects the back, flanks, and abdomen, and usually spares the axilla, groin, and scalp

    • Mild to more severe changes: faint reticulate pinkness or fine cracks to deep redness and cracking

  • Risk factors

    • Increased risk with age and more common in the elderly as is due to abnormal keratin production and lower amount of skin fatty acids

    • Worsened with cold, dry weather

  • Diagnosis

    • Physical exam

  • Treatment

    • Risk factor modification: humidity, indoors; avoid rough clothing and synthetic fibers, and avoid vasodilators if found to worsen itching (caffeine, alcohol, hot water).

    • Topical management: avoid topical anesthetic and antihistamines including topical corticosteroids for brief course. Apply menthol/camphor lotions, oatmeal baths, and pramoxine (PramaGel, Prax, Pramosone).

    • Oral antipruritic therapy.

      ASA, doxepin, antihistamines, and sedating vs nonsedating (hydroxyzine vs cetirizine)

24.2.2 Atopic Dermatitis

  • Presentation

    • “The itch that rashes” with scratching

    • Red and edematous crusted exudates, scaling commonly on the face particularly the cheeks, scalp, extensor surfaces of arms and legs, and trunk in infants and toddlers

    • Older children and adults commonly present with rash to flexor surfaces of wrists, ankles, warm or sweaty fossae (antecubital, popliteal), hands, and anogenital region

      • Usual onset within the first 24 months of life; 90 % of patients are diagnosed by age 5-years-old.

    • Appearance varies depending on chronicity

24.2.3 Types

  • Acute atopic dermatitis – characterized by weeping, crusted lesions with associated vesicles

  • Subacute atopic dermatitis – dry and scaly red plaques and papules

  • Chronic atopic dermatitis – lichenification of skin, related to chronic scratching resulting in thick, scaly localized plaques often associated with hyperpigmentation or hypopigmentation

    • Risk factors

      • Family history

      • Associated conditions: allergic rhinitis and asthma

      • Worsening with rough clothing; chemical irritants; emotional stress; foods such as cow’s milk, eggs, soy, wheat, fish, tree nuts, and peanuts; dust and molds; and cat dander

    • Diagnosis

      • Biopsy if uncertain or symptoms are refractory to treatment (particularly if disturbing sleeping, school or work function)

    • Management

      • General care

        • Same as xerosis, avoidance of environmental allergens and treat superimposed infection.

        • Dietary changes (elimination of common food antigens for short period for improvement) though controversial.

      • Medication

        • Topical steroids

          • Limited use for exacerbation; treat all palpable areas.

          • Ointment preferred to lotion as it moistens very dry skin and less likely for ointment base to act as allergen.

          • Mild flare: 3–4-day use.

          • Moderate flare: taper over 2 weeks.

          • Severe flare: high-potency topical steroids; avoid oral steroids in order to prevent rebound.

          • Hydrocortisone (0.5 %, 1 %, 2.5 %) for the face or groin.

          • Triamcinolone acetonide 0.1 % for the trunk and extremities.

      • More treatments

24.2.4 Contact Dermatitis

  • Most common dermatologic diagnosis

  • Presentation

    • Elderly and very young are more affected though it occurs in all demographics.

    • Atopy represents an independent risk factor. Irritant Contact Dermatitis

  • Sharply demarcated area of marked erythema (EM) and burning pain on exposed skin often followed by pruritus with onset of symptoms minutes to hours after exposure.

  • Often associated with pustular lesions (more common here than in allergic type).

  • Numerous known irritants: strong and weak acids such as acids of vinegar, heavy metals, wet cement, rubbing alcohol, nail polish remover, and soaps.

  • Remove offending stimulus and contaminated clothing, prolonged irrigation with water.

    • Risk factors

      • Exposure to specific agents

    • Diagnosis

      • Clinical

    • Treatment

      • Removal of offending agent

      • Antihistamines for itching

      • Topical corticosteroids (hydrocortisone) for small skin areas

      • Consideration of oral steroids for more severe reactions

24.2.5 Seborrheic Dermatitis

  • Abnormal epithelial function leads to redness and scaling with component of fungal overgrowth when Malassezia species release enzymes that cause local skin inflammation and scaling and underlying red patches.

  • Presentation

    • Itchy, oily, and scaling rash to the scalp and face particularly the nasolabial fold, midface, and eyebrows

    • Can have chest involvement and breast folds

    • May also be associated with blepharitis, otitis externa, and acne vulgaris

  • Risk factors

    • Immunocompromised state (malignancy, AIDS)

    • Cold, dry environments

    • Sun exposure

    • Emotional stress

    • Also associated with stroke patients, epilepsy, and Parkinsonism and nutritional deficiency

  • Diagnosis

    • Biopsy when unclear diagnosis

  • Treatment:


  • Initial therapy: over-the-counter shampoo, coal tar-based shampoo, or selenium sulfide shampoo

  • Antifungal shampoo (ketoconazole 2 % or ciclopirox 1 %)

  • Clobetasol 0.05 % shampoo for moderate to severe cases (high-potency steroid)

  • Betamethasone valerate 0.12 % foam or fluocinolone 0.01 % shampoo (medium-potency steroid)

Face and Body

  • First line

  • Antifungal against the inflammation-provoking Malassezia growth

    • Considered a maintenance medication

      • Ketoconazole 2 % cream or gel or foam

      • Ciclopirox 0.77 % gel or 1 % cream

      • Sertaconazole 2 % cream

    • Topical corticosteroids and calcineurin inhibitors

      • Acute exacerbations and thus intended for short-term use

    • Low-potency topical steroid

      • Hydrocortisone 1 % ointment or cream

      • Desonide 0.05 % foam, gel, lotion, cream, and ointment

      • Fluocinolone 0.01 % cream, solution, and oil

    • Topical calcineurin inhibitors

      • Tacrolimus 0.1 % ointment

      • Pimecrolimus 1 % cream

24.3 Parasitic Infections

24.3.1 Scabies

  • Resultant of mite bite and infestation and transmission by direct contact including fomite exposure

  • Presentation

    • Severe and intense itching particularly worse nocturnally leading to very small red papule followed by vesicle and even pustule formation

    • Pathognomonic burrow occurs in 10–20 % of cases; these are short, wavy gray lines on the surface of the skin most easily seen in webspaces and flexion points (wrist and elbows).

    • Commonly involves the trunk, genitalia, gluteal crease, and areola of the breast

  • Risk factors

    • Crowded spaces (shelters, nursing homes)

    • Poor hygiene or nutritional status

    • Young children

    • Homelessness

    • Dementia

    • Sexually transmitted diseases

  • Diagnosis

    • Burrow ink test (BIT) – burrow ink test involves coloring the burrow with a washable marker; wash area and look for a marker to penetrate burrow and thus make them more evident.

    • Burrow scraping – apply mineral oil, scrape burrow on its long axis with #15 blade placed on a slide, and view under low-power microscope for mites, eggs, etc.

  • Treatment

    • Consists of environmental and local infection control, as well as symptomatic management.

    • Be aware that pruritus can continue 2–6 weeks posttreatment; this improves as skin sloughs.

  • Environmental control

    • Wash all clothing, bedding, etc. in hot water (at least 140 F).

    • Those which cannot be washed should be sealed in a plastic bag for 2 weeks.

  • Infection control

    • First line: permethrin 5 % cream

    • Apply to the neck down including the perineum and crevices in adults. In children and the immunocompromised, also apply to the face and head.

    • Wash off after 8–14 h followed by another application in 1 week.

    • Second line: ivermectin 200 mcg/kg oral agent given once followed by repeat dose in 14 days

      • Used in patients who cannot apply permethrin cream or those refractory to first-line agent

    • Tertiary treatments

      • Eurax 10 % cream (can be used in infants and during pregnancy or lactation)

      • Precipitated sulfur 6 % in petroleum (no safety data available)

  • Symptomatic control

    • See pruritus management.

24.3.2 Bedbugs

Nov 20, 2017 | Posted by in Uncategorized | Comments Off on Skin Problems
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