© Springer International Publishing Switzerland 2017Bobby Desai and Alpa Desai (eds.)Primary Care for Emergency Physicians10.1007/978-3-319-44360-7_24
24. Skin Problems
Emergency Medicine, UF Health Shands Hospital, Gainesville, FL 32610, USA
Dermatology, UF Health Shands Hospital, Gainesville, FL 32606, USA
KeywordsAtopyDermatitisParasitic infectionsScabiesBedbugsLiceFungal infectionsMelismaErythema nodosumAcne
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)
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
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
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
“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
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
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
Biopsy if uncertain or symptoms are refractory to treatment (particularly if disturbing sleeping, school or work function)
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.
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.
24.2.4 Contact Dermatitis
Most common dermatologic diagnosis
Elderly and very young are more affected though it occurs in all demographics.
Atopy represents an independent risk factor.
126.96.36.199 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.
Exposure to specific agents
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.
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
Immunocompromised state (malignancy, AIDS)
Cold, dry environments
Also associated with stroke patients, epilepsy, and Parkinsonism and nutritional deficiency
Biopsy when unclear diagnosis
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
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
Resultant of mite bite and infestation and transmission by direct contact including fomite exposure
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
Crowded spaces (shelters, nursing homes)
Poor hygiene or nutritional status
Sexually transmitted diseases
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.
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.
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.
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
Eurax 10 % cream (can be used in infants and during pregnancy or lactation)
Precipitated sulfur 6 % in petroleum (no safety data available)
See pruritus management.
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Results from a hypersensitivity reaction due to a bite from parasite of Cimicidae family
Releases an anesthetic in its saliva thus preventing host awareness of bite
Moderate to severe itching that starts as red papules with central clearing but can progress in later reactions to wheals and vesicles
Bites are in linear pattern, distribution to the face and neck, arms and legs, and back; spares popliteal fossa and axilla
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