The Generalized Rash: Diagnostic and Treatment Considerations
Transcription
The Generalized Rash: Diagnostic and Treatment Considerations
The Generalized Rash: Diagnostic and Treatment Considerations Lorraine L. Rosamilia, MD Staff Dermatologist – Scenery Park Geisinger Health System State College, PA Objectives Upon completion of this presentation, participants should be able to: • Identify common/uncommon, acute/chronic, indolent/emergency etiologies of generalized skin eruptions • Determine utility of diagnostic testing for generalized skin eruptions • Initiate management for generalized skin eruptions and further identify cases in which additional consultation is prudent Generalized skin eruptions • Common – – – – – – – – – – – – Dermatitis (atopic, contact, essential, seborrheic) Exanthems (viral, drug) Psoriasis Id reaction Arthropod assault Urticaria Tinea corporis/Majocchi granuloma Lichenoid reactions Pityriasis rosea Erythema multiforme Other infectious (VZV, Lyme, Staph, molluscum) Other (Grovers, folliculitis, miliaria, tinea versicolor) Generalized skin eruptions • Uncommon – Autoimmune blistering diseases (BP, PV, DH) – Connective tissue disease – Cutaneous T-cell lymphoma – Septicemia (gono/meningococcemia) – Other rare infections (syphilis, HIV, RMSF, SSSS, TSS, disseminated viral) – Rare drug eruptions (SJS, TEN, DRESS, AGEP, EGFRi, other chemo) – Other (GA, paraneoplastic, Sweets, idiopathic) Generalized skin eruptions • Most are acute on chronic – Dermatitis, psoriasis, lichenoid, chronic urticaria, tinea versicolor, Grovers, CTCL, GA, blistering diseases, tinea corporis, folliculitis • Acute – Acute urticaria, exanthems, drug, EM, id, arthropod, pityriasis rosea, infection, Sweets Emergencies • • • • • • Urticaria with airway dysfunction SJS/TEN, DRESS Disseminated viral, septicemia TSS, SSSS RMSF, Lyme Any generalized eruption with unstable volume loss or severe mucosal involvement Clinical clues • • • • • • • • Distribution, distribution, distribution Morphology, morphology, morphology Symptoms, symptoms, symptoms, symptoms Medication, dietary, and topical history Travel history, sick contacts Occupation Immune status, comorbidities Gestalt Diagnostics • • • • • Infectious parameters (CBC, titers, cultures) Skin scraping (scabies prep, KOH, Tzanck) Skin biopsy (+/- DIF, tissue culture) R/O DRESS (CBC/diff, CMP, TSH) Hypovolemia parameters (BP, BMP, UA) Management • ‘Do-nothing’ rashes, symptom control – Pityriasis rosea, mild exanthems, mild urticaria, miliaria, Grovers, molluscum, GA, • Topical control – Localized psoriasis or dermatitis (steroids, emollients) – Localized tinea (antifungals) – Localized lichenoid (steroids) – Mild folliculitis (antimicrobial, barrier topicals) – Scabies (permethrin) Management • Systemic therapy – Diffuse dermatitis, drug esp DRESS, blistering diseases, lichenoid (oral steroids, inpatient?) – Diffuse tinea/Majocchi (oral antifungals) – Diffuse urticaria, symptomatic control of pruritus (systemic antihistamines) – Infection (systemic antimicrobials) – Neoplasia/paraneoplasia, CTD (complex) Cheat sheets • Clinical features of dermatitis, psoriasis, and tinea can distinguish them from each other – Dermatitis – background xerosis, classic atopic distribution for age, eyelid involvement – Psoriasis – flexors, scalp, gluteal cleft distribution, silvery scale – Tinea – annular scaly plaques with central clearing, sometimes follicular prominence Cheat sheets • Scabies prep and KOH clearly diagnose scabies infestation and tinea variants respectively • Skin biopsy is helpful for blistering diseases, CTD, lichenoid eruptions, and some infections • Skin biopsy is often not helpful for urticaria, exanthema, some drug reactions, and some phases of cutaneous lymphoma • Psoriasis, dermatitis, erythema multiforme, Grovers, folliculitis, GA, PR, and id are typically clinical diagnoses Cheat sheets • Systemic steroids ameliorate psoriasis only while taking them, with resultant rebound • Systemic steroids will lead to muted inflammation/diagnostic clues on skin biopsy • Topical and systemic steroids will cause tinea to persist and worsen • Extensive scabies is better managed with combination of oral and topical antiparasitic agents, herd decontamination Conclusions • Common disorders like psoriasis, dermatitis, and tinea are often clinical and/or point-ofcare diagnoses • Skin biopsy can be unhelpful for certain conditions, particularly exanthema • It is important to distinguish between indolent and emergency presentations of generalized eruptions, as mortality rates hinge upon time to diagnosis, treatment, and supportive care Thank you! Lorraine L. Rosamilia, MD [email protected]