Dermatological Emergencies Research Articles

Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis and Treatment With a Biologic: A Case Report

One of the most dangerous dermatologic emergencies is Stevens-Johnson Syndrome (SJS)/toxic epidermal necrolysis (TEN). Although a rare disease, it can often lead to significant mortality. In this case report, we present a 77-year-old man who developed a sloughing rash that was secondary to a nonsteroidal anti-inflammatory drug. In addition to the recommended supportive care, the patient was treated with etanercept, a new, less commonly used intervention. We provide a brief review of SJS/TEN. Nonsteroidal anti-inflammatory drugs are a rare cause of SJS/TEN, and additionally, the use of biologics is a novel treatment modality for SJS/TEN.

Dermatological emergencies: evolution from 2008 to 2014 and perspectives.

Our dermatological department includes a dermatological emergency unit (DEU) whose activity has grown in recent years. An audit to characterize the activity of our DEU and its evolution in terms of medical demographics of the area. We collected the following data from administrative services: number of patients consulting each year in the DEU and in the general emergency unit (GEU) of our hospital between 2008 and 2014; daily and seasonal activity of the DEU; occurrence of a second event in the department and proportion of patients from the DEU who were hospitalized and why. From the medical charts of a random sample of patients consulting in the first 15 days of January and August 2014, we studied the epidemiological profile, time to consultation and diagnoses. Data related to medical demographics (number of general practitioners and dermatologists) between 2007 and 2014 and projections were obtained. The activity in the DEU increased by 67% between 2008 and 2014 but remained stable in the GEU over the same period. The activity was higher on Mondays and in the summer (+30%). More than 15% of the patients were seen a second time in outpatient consultation; 1.2% were hospitalized. Infectious dermatosis was the main reason for consultation; seasonal-disease consultations were more frequent in the summer. Less than 40% of patients consulted in the first week after disease onset. Medical demographics continually decreased since 2007 in Paris and suburbs and will continue to decrease in the next years. The increasing activity of our DEU parallels the decrease in medical demographics in Paris. The proportion of patients hospitalized was low, in part due to specific healthcare networks implemented for some life-threatening dermatoses independent of the DEU. A better coordination between hospital and private practitioners for managing dermatologic emergencies, taking into account the decrease in medical demographics, is warranted.

Dermatological emergencies: one-year data analysis of 8,620 patients from the largest Portuguese tertiary teaching hospital.

Skin conditions frequently lead to emergency department (ED) visits. While most are benign in course, some will present as true dermatological urgencies/emergencies, requiring admission. To present data on skin diseases most frequently found in the ED, and those most frequently requiring admission at the largest Portuguese tertiary teaching hospital, and to explore an association between epidemiological variables and frequency of diagnoses within this context. A retrospective study was conducted on all patients examined during 2012 for dermatology emergency consultation (DEC) at the Hospital de Santa Maria, Lisbon, Portugal. Association between epidemiological variables (gender and age of patients, and season of the year) and frequency of diagnoses was investigated. In total, 8,620 patients were examined by a dermatologist in the ED, constituting 3.9% of all ED visits in our centre. Overall, 333 diagnoses were made, the most frequent of which was eczema not-otherwise-specified (9.4%). However, infectious and parasitic diseases constituted the leading motive for DEC (31.5%). Only 264 patients were admitted, with 65 diagnoses leading to admission. Nine diagnoses alone led to 60% of all admissions. Infectious and parasitic diseases constituted the leading cause of admission (34.7%). An association between frequency of diagnoses and gender, age, and season was identified. Despite the variety of dermatological pathologies, only a limited group of diseases was responsible for most of the true dermatological emergencies. Therefore, in the absence of a readily available dermatologist, knowledge of these entities, as well as demographic and environmental data, may help to improve the management of these patients.

Dermatologic Emergencies in a Tertiary Hospital: A Descriptive Study

Background and objectiveDermatology in-house call is uncommon in the Spanish national health system. The objective of the present study was to define the groups of dermatologic diseases and conditions most frequently seen in the emergency department and to evaluate the need for dermatology in-house call in the training of medical residents. Material and methodsWe performed a descriptive study of all patients who attended the emergency department with a skin complaint during a 1-year period (June 2013 to May 2014) and were assessed by 9 dermatology residents. The study variables were date/day, sex, age, diagnosis, special surgical procedures, additional laboratory tests, and need for hospitalization and/or follow-up. We also evaluated patients attending their first scheduled visit to the dermatologist between January and June 2014 in order to compare the most frequent conditions in both groups. ResultsA total of 3084 patients attended the emergency room with a skin complaint (5.6% of all visits to the emergency department), and 152 different diagnoses were made. The most frequent groups of diseases were infectious diseases (23%) and eczema (15.1%). The specific conditions seen were acute urticaria (7.6%), contact dermatitis (6.1%), and drug-induced reactions (4.6%). By contrast, the most frequent conditions seen in the 1288 patients who attended a scheduled dermatology appointment were seborrheic keratosis (11.9%), melanocytic nevus (11.5%), and actinic keratosis (8%). A follow-up visit was required in 42% of patients seen in the emergency department. Fourth-year residents generated the lowest number of follow-up visits. ConclusionsWe found that infectious diseases and eczema accounted for almost 40% of all emergency dermatology visits. Our results seem to indicate that the system of in-house call for dermatology residents is very useful for the hospital system and an essential component of the dermatology resident's training program.

Catastrophic Drug-Drug Interactions in Psychopharmacology

Drug interactions may reflect pharmacokinetic processes, pharmacodynamic processes, or both. Some interactions are classified as idiosyncratic, as their mechanisms are not yet understood. Drug interactions involving psychotropic medications are ubiquitous; they typically result in changes in drug levels and/or drug effects. Fortunately, most drug interactions in psychiatry do not result in serious harm. Some drug interactions, however, are potentially catastrophic. The focus of this review is on the principal mechanisms of drug interactions and on potentially serious and life-threatening adverse consequences (eg, serotonin syndrome, hypertensive crises, arrhythmias, anticholinergic toxicity, seizures, dermatologic emergencies, bleeding, respiratory depression) of drug interactions in psychiatry. Patients with refractory psychiatric disorders, as well as medical comorbidity, often require treatment with complex drug regimens. The risk of catastrophic drug interactions involving psychotropic medications may be minimized by knowledge of the mechanisms of drug interactions and by familiarity with the rare, yet potentially life-threatening drug interactions that involve psychotropic medications. [ Psychiatr Ann . 2016;46(8):439–447.]

Psychological sequelae of toxic epidermal necrolysis: further insights

Stevens–Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) may be considered the most dramatic of all dermatological emergencies, characterized by a cataclysmic immune response to a stimulus, most usually a drug, and widespread skin loss. It is, to the lay person, the stuff of horror movies. From this perspective, the conclusions of the valuable paper published in the BJD this month by Dodiuk‐Gad et al. are perhaps unsurprising: that is, survivors of SJS/TEN carry with them a burden of psychological morbidity in the aftermath of what is a devastating life event.1 Butt et al. were the first group to assess in a qualitative fashion the impact of TEN on survivors.2 3 The language and phraseology used by patients in these landmark papers were haunting: ‘what I looked like made people…disgusted and scared…as if I was turned in to a monster’; ‘I am scarred in my mind as well as scarred on my body…’. Lew et al. assessed the psychological sequelae of drug reaction with eosinophilia and systemic symptoms, another of the severe cutaneous adverse reaction (SCAR) syndromes, and found similar experiences of anxiety, depression and post‐traumatic stress disorder (PTSD) among survivors.4

Prevalence and pattern of dermatological disorders in the pediatric emergency service

BackgroundDermatological disorders are common in children. This study sought to describe the prevalence and pattern of dermatological emergencies encountered in the pediatric emergency room (ER). MethodsThis was a retrospective study of patients with dermatological complaints visiting the pediatric ER at a teaching hospital in Saudi Arabia during the year 2014. ResultsA total of 44,162 ER visits were recorded among children aged ⩽13years, of which 2070 (4.7%) involved dermatological complaints. Over 80 dermatological conditions were encountered, the most common of which was atopic dermatitis (10.8%), followed by urticaria (9.7%). Categorization of diseases according to etiology revealed that the largest proportion of patients had infectious diseases (25.2%). Rare genetic disorders and life-threatening dermatological conditions were also encountered. A total of 10.5% of patients did not receive a diagnosis. ConclusionsOur study revealed a high frequency and wide spectrum of dermatological disorders in the pediatric ER. Considering the high rate of undiagnosed cases, this study highlights the need to objectively measure physicians’ abilities to diagnose dermatological disorders. Identification of common and potentially dangerous disorders can aid in the development of educational resources for trainees and in the allocation of future resources for the treatment of common conditions.

Core Content for Undergraduate Medical Education in Spain: Recommendations of the Instructors’ Group of the Spanish Academy of Dermatology and Venereology (AEDV)

BackgroundSkin problems are among the most frequent reasons for seeking medical attention in primary care. In recent years, as a result of the process of adapting medical curricula to the requirements of the European Higher Education Area, the amount of time students spend learning the concepts of dermatology has been reduced in many universities. Material and methodsIn order to reach a consensus on core content for undergraduate education in dermatology, we sent a survey to the 57 members of the instructors’ group of the Spanish Academy of Dermatology and Venereology (AEDV), asking their opinions on what objectives should be set for a dermatology course in Spain. A total of 131 previously selected objectives were listed. We then applied the Delphi method to achieve consensus on which ones the respondents considered important or very important (score ≥4 on a Likert scale). ResultsNineteen responses (33%) were received. On the second round of the Delphi process, 68 objectives achieved average scores of at least 4. The respondents emphasized that graduates should understand the structure and functions of the skin and know about bacterial, viral, and fungal skin infections, the most common sexually transmitted diseases (STDs), and the 4 main inflammatory dermatoses. Students should also learn about common complaints, such as itching and bald patches; the management of dermatologic emergencies; purpura and erythema nodosum as signs of internal disease; and the prevention of STDs and skin cancer. During clinical clerkships students should acquire the communication skills they will need to interview patients, write up a patient's medical history, and refer the patient to a specialist. ConclusionsThe AEDV's group of instructors have defined their recommendations on the core content that medical faculties should adopt for the undergraduate subject of dermatology in Spain.

Dermatologic emergencies

Dermatologic emergencies represent about 8–20% of the diseases seen in the Emergency Department of hospitals. It is often a challenge for primary care physicians to differentiate mundane skin ailments from more serious, life threatening conditions that require immediate intervention. In this review we included the following conditions: Stevens-Johnson syndrome/toxic epidermal necrosis, pemphigus vulgaris, toxic shock syndrome, fasciitis necrotising, angioedema/urticaria, meningococcemia, Lyme disease and Rocky Mountain spotted fever.

Contenidos fundamentales de la Dermatología en el grado de medicina en España. Recomendaciones del grupo de profesores de la Academia Española de Dermatología y Venereología

BackgroundSkin problems are among the most frequent reasons for seeking medical attention in primary care. In recent years, as a result of the process of adapting medical curricula to the requirements of the European Higher Education Area, the amount of time students spend learning the concepts of dermatology has been reduced in many universities. Material and methodsIn order to reach a consensus on core content for undergraduate education in dermatology, we sent a survey to the 57 members of the instructors’ group of the Spanish Academy of Dermatology and Venereology (AEDV), asking their opinions on what objectives should be set for a dermatology course in Spain. A total of 131 previously selected objectives were listed. We then applied the Delphi method to achieve consensus on which ones the respondents considered important or very important (score≥4 on a Likert scale). ResultsNineteen responses (33%) were received. On the second round of the Delphi process, 68 objectives achieved average scores of at least 4. The respondents emphasized that graduates should understand the structure and functions of the skin and know about bacterial, viral, and fungal skin infections, the most common sexually transmitted diseases (STDs), and the 4 main inflammatory dermatoses. Students should also learn about common complaints, such as itching and bald patches; the management of dermatologic emergencies; purpura and erythema nodosum as signs of internal disease; and the prevention of STDs and skin cancer. During clinical clerkships students should acquire the communication skills they will need to interview patients, write up a patient's medical history, and refer the patient to a specialist. ConclusionsThe AEDV's group of instructors have defined their recommendations on the core content that medical faculties should adopt for the undergraduate subject of dermatology in Spain.

A review of the diagnosis and management of erythroderma (generalized red skin).

Erythroderma is a condition caused by several etiologies that result in red inflamed skin on 90% or more of the body surface. To optimize the diagnosis and management of the erythrodermic patient, healthcare professionals should be familiar with the underlying etiologies and treatment modalities. Patients with erythroderma require immediate attention as they may face a variety of medical complications. Early detection and effective management of these complications significantly reduce mortality and morbidity of this potential dermatologic emergency. This review highlights the underlying common diagnoses, assessment, and management of the patient with erythroderma.

Interventions for reducing wrong-site surgery and invasive clinical procedures.

Specific clinical interventions are needed to reduce wrong-site surgery, which is a rare but potentially disastrous clinical error. Risk factors contributing to wrong-site surgery are variable and complex. The introduction of organisational and professional clinical strategies have a role in minimising wrong-site surgery. To evaluate the effectiveness of organisational and professional interventions for reducing wrong-site surgery (including wrong-side, wrong-procedure and wrong-patient surgery), including non-surgical invasive clinical procedures such as regional blocks, dermatological, obstetric and dental procedures and emergency surgical procedures not undertaken within the operating theatre. For this update, we searched the following electronic databases: the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (January 2014), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2014), MEDLINE (June 2011 to January 2014), EMBASE (June 2011 to January 2014), CINAHL (June 2011 to January 2014), Dissertations and Theses (June 2011 to January 2014), African Index Medicus, Latin American and Caribbean Health Sciences database, Virtual Health Library, Pan American Health Organization Database and the World Health Organization Library Information System. Database searches were conducted in January 2014. We searched for randomised controlled trials (RCTs), non-randomised controlled trials, controlled before-after studies (CBAs) with at least two intervention and control sites, and interrupted-time-series (ITS) studies where the intervention time was clearly defined and there were at least three data points before and three after the intervention. We included two ITS studies that evaluated the effectiveness of organisational and professional interventions for reducing wrong-site surgery, including wrong-side and wrong-procedure surgery. Participants included all healthcare professionals providing care to surgical patients; studies where patients were involved to avoid the incorrect procedures or studies with interventions addressed to healthcare managers, administrators, stakeholders or health insurers. Two review authors independently assesses the quality and abstracted data of all eligible studies using a standardised data extraction form, modified from the Cochrane EPOC checklists. We contacted study authors for additional information. In the initial review, we included one ITS study that evaluated a targeted educational intervention aimed at reducing the incidence of wrong-site tooth extractions. The intervention included examination of previous cases of wrong-site tooth extractions, educational intervention including a presentation of cases of erroneous extractions, explanation of relevant clinical guidelines and feedback by an instructor. Data were reported from all patients on the surveillance system of a University Medical centre in Taiwan with a total of 24,406 tooth extractions before the intervention and 28,084 tooth extractions after the intervention. We re-analysed the data using the Prais-Winsten time series and the change in level for annual number of mishaps was statistically significant at -4.52 (95% confidence interval (CI) -6.83 to -2.217) (standard error (SE) 0.5380). The change in slope was statistically significant at -1.16 (95% CI -2.22 to -0.10) (SE 0.2472; P < 0.05).This update includes an additional study reporting on the incidence of neurological WSS at a university hospital both before and after the Universal Protocol's implementation. A total of 22,743 patients undergoing neurosurgical procedures at the University of Illionois College of Medicine at Peoria, Illinois, United States of America were reported. Of these, 7286 patients were reported before the intervention and 15,456 patients were reported after the intervention. The authors found a significant difference (P < 0.001) in the incidence of WSS between the before period, 1999 to 2004, and the after period, 2005 to 2011. Similarly, data were re-analysed using Prais-Winsten regression to correct for autocorrelation. As the incidences were reported by year only and the intervention occurred in July 2004, the intervention year 2004 was excluded from the analysis. The change in level at the point the intervention was introduced was not statistically significant at -0.078 percentage points (pp) (95% CI -0.176 pp to 0.02 pp; SE 0.042; P = 0.103). The change in slope was statistically significant at 0.031 (95% CI 0.004 to 0.058; SE 0.012; P < 0.05). The findings of this update added one additional ITS study to the previous review which contained one ITS study. The original review suggested that the use of a specific educational intervention in the context of a dental outpatient setting, which targets junior dental staff using a training session that included cases of wrong-site surgery, presentation of clinical guidelines and feedback by an instructor, was associated with a reduction in the incidence of wrong-site tooth extractions. The additional study in this update evaluated the annual incidence rates of wrong-site surgery in a neurosurgical population before and after the implementation of the Universal Protocol. The data suggested a strong downward trend in the incidence of wrong-site surgery prior to the intervention with the incidence rate approaching zero. The effect of the intervention in these studies however remains unclear, as data reflect only two small low-quality studies in very specific population groups.

Dermatological consultations in an observation unit of an emergency department in Italy.

Dermatological emergencies exist and should not be underestimated. On the other hand, many accesses to the emergency department (ED) of patients with dermatological conditions are unjustified. Our main objective is to describe dermatological conditions seen in an ED observation unit (EDOU). Secondly, our aim is to identify alarm symptoms and signs of 'true emergencies'. We conducted a prospective study, including dermatological patients admitted to EDOU of the University Hospital of San Martino, Genoa, Italy, in 3 years. Overall 372 patients were studied. The most common condition seen was infection (41.67%) (mainly bacterial), followed by atypical exanthem (13.98%) and vasculitis (11.29%). The highest rate of cases peaked in May (13%); infectious diseases showed two peaks (spring and autumn). Given constraints involved in health care today, it is crucial to understand which dermatological presentations are 'true emergencies'. In such a scenario knowing the epidemiology of dermatological emergencies and the alarming skin signs and symptoms might be useful.

Nécrolyse épidermique toxique (syndrome de Lyell). À propos de 2 cas.

Toxic Epidermal Necrolysis (TEN) is a real dermatological emergency, requiring early diagnosis and early management, using extensive therapeutic treatment. This iatrogenic complication is fortunately rare, but the prognosis remains severe despite the early management in special care units. We report here two cases of Toxic Epidermal Necrolysis in two men, aged 77 and 46 years old. By the way, we will review clinical and laboratory signs and will emphasize the frequency and the severity of iatrogenic drug eruptions.

Dermatological conditions presenting at the Emergency Department in Siena University Hospital from 2006 to 2011

Published studies on emergency dermatology consultations are few because there are few dermatology emergency units in the world. No study has yet described the Italian situation. To quantify and characterize patients evaluated in our dermatology emergency unit from 2006 to 2011. We studied personal details, diagnosis, annual trend of cases, emergency level and hospitalization of dermatology cases over the 6-year period. A total of 12,226 patients were evaluated. The most numerous diagnostic group was infections (27.1%), followed by non-specific and descriptive diagnosis (22.5%), skin conditions caused by mechanical or physical agents (13.1%), eczematous diseases (10.5%), insect bites (9.5%) and urticaria/angio-oedema (8.8%). The most common indications for admission to hospital were skin conditions caused by mechanical or physical agents (33.3%), infections (27.5%), drug eruption (15.9%) and autoimmune or inflammatory disorders (7.4%). Emergency dermatology cases followed a variable annual trend, with more consultations in the summer months. This is the first long-term retrospective analysis of a large series of dermatology emergency patients. It provides useful quantitative and qualitative information on cases for physicians and the national health system for the purposes of improving patient care and cost-effectiveness.

Rare neonatal dermatological emergency: Staphylococcal scalded skin syndrome (Ritter disease)

A sixteen days old newborn was admitted with exfoliating erythematous lesions over the trunk, face, back and extremities for two days. A diagnosis of Staphylococcal Scalded Skin Syndrome (SSSS) also known as Ritter disease was made clinically. The child responded to Injection amoxycillin-clavulinic acid (Augmentin) and topical fusidic acid. Lesions gradually resolved over 72 hours and child was discharged after ten days of hospitalization. SSSS represents a rare dermatology emergency in neonate which if untreated can be life threatening.

Staphylococcal scalded skin syndrome: A dermatological emergency in pediatrician′s hand

Staphylococcal scalded skin syndrome (SSSS) is a toxin-mediated exfoliating skin condition predominated by desquamation and blistering. Retrospective analysis of cases between 2010 and 2012, over a period of 2 years identified eight cases with SSSS. All cases identified were under 1 year of age. Erythema and exfoliative lesions were the initial symptoms followed by fever. Blood culture was positive for Staphylococcal aureus in 25% cases and pus culture positive in 37%. No methicillin-resistant S. aureus were found and all responded to common antibiotics. Due to early identification and antibiotic treatment, all the cases recovered completely.

Intérêt d’une consultation dermatologique d’urgence dans un centre hospitalier régional

Dermatologists, both as hospital and as resident practitioners, are often requested to see emergencies of their discipline, although appointment planning are already fully booked months in advance. Orleans Regional Hospital (ORH) has opened a department of dermatological emergency consultation to try to help with this issue. A prospective, descriptive and consecutive study on patient characteristics was conducted during its first year operating. In September 2011, we opened a department of dermatological emergency consultation. Reception is skin disorders evaluated by physicians or nurses as "emergencies", according to predefined criteria. Follow-up visits are performed in the afternoon. Within one year, 2209 medical visits were conducted, with an average of 8,7 emergency visits per day. The maximum numbers of patients treated by our dermatological emergency unit in one single morning was 19. Mondays were the busiest day of the week. The average age of a patient attending the department was 33 years, with 29% of pediatric patients (under 15 years old). The majority of patients presented spontaneously (43%), or were referred by general practitioners (25%). Adult and pediatric emergency departments sent 8% of patients. The two main reasons for consultation were rash (48%) and pruritus (16%). Diagnoses observed were mainly infections (24%) and eczema (14%). Scabies accounted for 9% of all diagnoses. In the aftermath of an emergency dermatological consultation, 84 patients were hospitalized, including 74 in the dermatology department of Orleans hospital totalling 505 days of hospitalization. The value of a dermatological emergency consultation is well demonstrated in areas where more medical services are available (such as cities with University hospitals available). It is even more justified in areas with a deficit of healthcare service availability such as Central France.

Pediatric Dermatological Emergencies: An Overview

Dermatological emergencies including those in pediatric age group comprise of dermatoses where there is severe alterations in structure and function of the skin. Some of these may result in acute skin failure that needs early recognition, and often hospitalization, with careful monitoring and at times management in intensive care unit on the pattern of 100% burns in order to minimize the associated morbidity and mortality. Multi-disciplinary approach with synchronized team of dermatologist, pediatrician, critical care physician and skilled nursing staff is advisable. In this review article, we describe various pediatric dermatological emergencies commonly encountered in clinical practice and observed in various studies.

Dermatologic Emergencies: Descriptive Analysis of 861 Patients in a Tertiary Care Teaching Hospital

Introduction and objectivesMost Spanish hospitals do not have an on-call dermatologist. The primary objective of our study was to determine the profile of patients visiting our hospital's emergency department for dermatologic conditions; our secondary objective was to analyze the case-resolving capacity of the on-call dermatologist. Material and methodsProspective study that included patients with dermatologic conditions treated in the emergency department of a hospital with an on-call dermatology resident during a 2-month period. We collected data on sex, age, diagnosis, days since onset, whether or not the emergency visit was justified, referral (self-referral or other), continued care, and the main reason for the visit. To analyze the case-resolving capacity of the on-call dermatologist we assessed the percentage of direct discharges, the diagnostic tests performed, and the percentage of revisits. ResultsThe on-call dermatologist attended 861 patients (14.4 patients per day), of whom 58% were women and 42% men. In total, 131 different diagnoses were made; the most common were infectious cellulitis, acute urticaria, and herpes zoster. Only half of the visits were justifiable as emergencies (95% of patients <30 years of age had conditions that did not justify emergency care, compared to 6% of patients >65 years, P<.005). The on-call dermatologist discharged 58% of the patients directly and the revisit rate was 1%. In 4 of 5 emergency visits no diagnostic tests were required. ConclusionsThe profile of patients seeking emergency dermatologic care is variable. Half of the emergency visits were not justified, and unjustified visits were especially common in younger patients. The case-resolving capacity of the on-call dermatologist was high.