Life Threatening

Dermatoses
and Emergency In
Dermatology
Abraham Arimuko
Departemen Kulit dan Kelamin
RSPAD Gatot Soebroto Jakarta

 Emergency situations can occur even in the

doctors office.
An emergency can be reviewed for dermatologic conditions: questioning, looking for signs of
severity, examining mucous membranes are
important.
Recognize these situations at their beginning in
order to undertake appropriate emergency
procedure.

Dermatologic cases
Cutaneous Adverse Drug Reaction
Drug Eruption with Eosinophilia and
Systemic Syndrome (DRESS)
Angioedema
Anaphylactic Shock
Staphylococcal Scalded Skin Syndrome
(SSSS)
Purpura Fulminans

Toxic epidermal necrotizing (T.E.N.)

and StevensJohnson syndrome (SJS)
Severe, drug-induced skin reactions with a
high morbidity and mortality.
TEN-SJS : different severity levels of this
disease.
The difference is based on the evaluation of
involved body surface ( BSA).
The mortality is about 30% for TEN.
Drugs are nearly always involved, but in about
20% of the cases they are not identified

 Drugs high risk induce : allopurinol,

sulfonamides, carbamazapine,
lamotrigine, nevirapine, oxicamNSAIDs, phenobarbital, and phenytoin.
the prognosis of the patient :
supportive management is most
Treatments : corticosteroids,
antihistamine, immunoglobulin, etc.

Classification of the consensus

( Bastuji-Garin et al.)

Clinical finding :
Beginning signs = difficult to recognize : isolated
fever, sore throat, cough or burning eyes.
The cutaneous eruption : erythematous macules,
dark purpuric centres ( target lesion) : +/ Within 13 days, flaccid blisters, sheet-like
epidermal detachment appear, with Nikolskys
sign.
Mucous membrane erosions

The signs :
A rash accompanied by mucous
involvement.
Mouth
Genital
Conjuntiva

Tenderness of the skin with burn

sensation.
Adenomegaly.
High fever above 38.5C.

Erythema Exsudativum Multiforme Majus (EEMM),

Typical targets lesions on palms

Confluent purpuric macules and fl at atypical targets in SJS

Early lesions of toxic epidermal necrolysis

Detachment of large epidermal sheets in TEN with maculae; atypical target

lesions are still present

Therapeutic Concepts
Early Diagnosis
Management in the Emergency Room
Topical Treatment and Supportive
Care
Immuno-Modulating Treatment

DrugEruptionwithEosinophili
a and Systemic Symptoms
(DRESS)
This cutaneous ADR is also severe, with
mortality about 10%.
The delay often very long up to 8 weeks.
Organs can be involved: liver, kidney,
myocardium, lung, and central nervous system.
The culprit drugs : carbamazepine, allopurinol,
hydantoin, lamotrigin, sulfonamides,
minocycline, non-steroidal anti-inflammatory
drugs, nevirapine, calcic inhibitors, methyldopa,
terbinafin, neuroleptics, and dapsone.

Clinical :
Lichenoid type erythrodermia
Fever of more than 38.5C, Poor general
condition
Adenomegaly, in at least two localisations
Peri-orbital oedema
Non-mucous involvement
Drugs known to be inductors
Very long delay between introduction of
the drug and beginning of the ADR

Angioedema
Type of urticaria, tender and thick
tumefaction of the skin, no pruritus,
it can be painful.
Lips, cheeks, peri-orbital areas and
tongue are often involved.
Dysphonia, hyper-salivation,
dysphagia, : involvement of the
pharyngeal, risk of glottis oedema.

Anaphylactic Shock
This occurs very quickly, usually less than 1 hour after introduction of the allergen.
It is very important to recognize it quickly because of its gravity. Diffuse erythema
with palmo-plantar pruritus, urticarial wheals, flush and dizziness are associated.
Mucous oedema frequently involves nose, eyes, mouth, lips and tongue. Gastro
enteric signs can induce in error:. Breathing becomes difficult because of oedema
and bronchospasm. Laryngal cough or asthma can occur.Decrease of arterial
pressure by intense vasodilata- tion is accompanied by tachycardia. Mental
confusion or seizure may be consequences of hypoxemia. Dizziness and intense
anxiety are always present.This is a true emergency; one should phone the
emergency mobile unit. While awaiting their arrival, the patient must be placed in
a supine position, oxygen (1015 l min1) should be administered, and epinephrin injected intramuscularly in deltoid region or in the anterior face of the thigh.
Average dosage in an adult is 0.5mg, in a child 0.01mg kg1. In absence of good
evolution, another injection can be administered 510min after. In the case of
bronchospasm, inhala- tion of salbutamol should be administered.Blood pressure,
cardiac rate, ventilation and con- sciousness must be supervised. Intravenous
infusion could be installed in order to perfuse macromolecules.The patient must
always be hospitalized, even if the status is good, because of the risk of rapid
recurrence.

Anaphylactic shock:
Signs that should alert :
Distal pruritic oedema and mucous
involvement
Flush phenomenon
Respiratory : bronchospasm
Digestive symptoms : abdominal pain,
nausea and dysphagia
Dizziness and anxiety
Low blood pressure and tachycardia

StaphylococcalScaldedSkin
Syndrome (SSSS)
Blistering, exfoliative dermatosis,
caused by the secretion of exotoxin from
Staphylococcus aureus
More frequently among children.
The risk of death is about 5% in
children.
Erythematous rash, sub-corneal
blistering Nikolskys sign is present.
The fluid in blisters is usually sterile.

Purpura Fulminans:
Observed with meningococcal infection
Young children
Begin with palpable purpura. larger
than 3mm in diameter. Some of them
may become necrotic.
Fever, chills, hypotension, meningoencephalitis, etc.
Treatment : Antibiotic

Purpura fulminans

The pathophysiology of disseminated intravascular coagulation in bacterial infection-related purpura

fulminans. Abbreviations: GAG, Glycosaminoglycans; aPC, activated protein C; PS, protein S; tPA, tissue
plasminogen activator; TM, thrombomodulin; ADP, adenosine diphosphate; TAFI, thrombinactivated fi
brinolysis inhibitor; PAI, plasminogen activator inhibitor-1; TF, tissue factor; TFPI, tissue factor pathway
inhibitor; ATIII, antithrombin 3; PC, protein C; EPCR, endothelial
protein C receptor; Roman numerals, clotting factor; n, neutrophil; m: macrophage

Meningococcemia
Haemorrhagic lesions : universal
distribution
Diameter haemorrhages greater than
2 mm
Poor overall condition
Nuchal rigidity
two of the above criteria are present

Conclusion:
Emergencies in the doctors office are
uncommon, but their severity requires that
the physician pays attention to the signs.
The need for equipment to respond to
every life- threatening situation depends
on the size of the practice, on the number
of patients coming to the location, and on
the proximity of the emergency service.