EMERGENCY IN

DERMATOLOGY
1. Erythema Multiforme
2. Stevens-Johnson Syndrome and
Toxic Epidermal Necrolysis
3. Acute Urticaria & Angioedema
4. Exfoliative Erythroderma Syndrome
5. Staphylococcal Scalded Skin Syndrome
 ERYTHEMA MULTIFORME

Def :reaction pattern of blood vessels in

the dermis with secondary
epidermal changes manifests
clinically as characteristic
erythematous iris-shaped papular
and vesicobulous lession typically
involving the extremities (especially
the palms and soles) and mucous
membranes.
 ERYTHEMA MULTIFORME

Etiol : a cutaneous reaction to variety of

antigenic stimuli

- drug : sulfonamide, phenytoin,

barbiturates, phenylbutazone,
penicillin, allopurinol

- infection : mycoplasma

- idiopathic : >50%
 ERYTHEMA MULTIFORME
Physical exam:

1. Erythema multiforme minor (EM Minor)

2. Erythema multiforme major (EM Major)

EM Minor :
litle, mucous membrane (-), systemic symp (-) Skin
lesion : developed ≥ 10 d
dull red macule (48h)
↓
papule
↓
vesicles & bullae in center of the papule
(iris, target like lesion)

Predilection sites : dorsa of hand, palms & soles,

forearms, feet, elbow & knees
ERYTHEMA MULTIFORME
 ERYTHEMA MULTIFORME
EM Major :
most often : drug reaction
→ severe, extensive, nikolsky sign (+),
mucous membrane always involment.
- Syst symptom : fever, prostration.
- Cheilitis & stomatitis, vulvitis & balanitis,
conjunctivitis can lead to keratitis & ulceration

→ Skin lesion : developed ≥ 10 d

- dull red macule (48h) → papule → vesicles &
bullae in center of the papule (iris, target like
lesion) → extensive bulllae

→ Predilection sites : = EM Minor + penis, vulva,

eyes & lip
ERYTHEMA MULTIFORME

EM Major
 ERYTHEMA MULTIFORME
 DD : psoriasis, secondary syphilis,
urticaria.
 Tx : glucocorticoid → prednisone 50-
80mg/d →quickly tapered
 STEVENS-JOHNSON SYNDROME &
TOXIC EPIDERMAL NECROLYSIS
 Def :
mucocutaneous drug-induced or idiophatic
reaction patterns characterized by skin
tenderness and erythema of skin and mucousa,
followed by extensive cutaneous and mucosal
epidermal necrotisand sloughing
→ potentially life-threatening due to
multisystem involvement
STEVENS-JOHNSON SYNDROME
&
TOXIC EPIDERMAL NECROLYSIS

 Pathogenesis : partially understand

drug (hapten)><keratinocytes
antigenic→cytokines → local cell death, fever &
malaise
 History : 1-3 w drug exposure
prodrome : fever, influenza-like sympt
→1-3d →mucocutaneous lessions
 STEVENS-JOHNSON SYNDROME
&
TOXIC EPIDERMAL NECROLYSISb

 Physical exam :
- prodromal rash : morbiliform, EM-like, diffuse erythema
- early : necrotic epidermis → macule with crinkled
surface → enlarge and coalesce → raised flaccid
blisters (Niklosky sign +)

- distribution : erythema face & extremities

few h/d↓
confluent
↓
generalized epidermal sloughing
↓
large denuded areas
mucous membranes : lips, buccal mucosa,
conjunctiva, genital & anal skin

*hair & nail : TEN → shed → eyelashes & nail

STEVENS-JOHNSON SYNDROME
&
TOXIC EPIDERMAL NECROLYSIS

STEVENS-JOHNSON
SYNDROME
STEVENS-JOHNSON SYNDROME
&
TOXIC EPIDERMAL NECROLYSIS

TOXIC EPIDERMAL NECROLYSIS

STEVENS-JOHNSON SYNDROME
&
TOXIC EPIDERMAL NECROLYSIS

 DD :
- early : EM major, exanthematous drug
eruption, scarlet fever, phototoxic
eruptions.
- fully evolved : EM major thermal burns,
SSSS, generalized bullous fixed drug
eruption, exfoliative dermatitis.

 Prognosis : ~extent of skin necrosis.

STEVENS-JOHNSON SYNDROME
&
TOXIC EPIDERMAL NECROLYSIS

 Management :
- withdrawal of suspected drugs
- best cared in intensive care unit
- manage replacement of IV fluids &
electrolytes ~III degree thermal burn
- syst glucocorticoid →high doses & early
- high doses iv immunoglobulin → TEN
- suction frequently → oropharyngeal
involvement
- treat complicating inf
- treat eye lesions →erythromycin oint
 ACUTE URTICARIA AND ANGIOEDEMA

 Def :
vascular reaction of the skin (trancient
edematous papules and plaques, usualy
pruritic) cause by local intercelular edema that
limited on the skin and mucousa.
ACUTE URTICARIA AND ANGIOEDEMA

 Patogenesis :
mast cell & basophil
immunology non immunology (cholinergik efect, physic
(hypersensitivity type I,type III) agent, chemical histamin liberator)

histamin
↓
↑capilary permeability&vasodilatation
↓
liquid transudation
ACUTE URTICARIA AND ANGIOEDEMA

Etiol : food, drugs, inhalants, infections, insect

bite, physical factor, psychis.

Clinical type :
- acute : acute onset & recurring over
<30 d → large wheals, associated
with angioedema →IgE dependent

- chronic : recurring >30 d → small&large

wheals → rare IgE →80%
unknown.
ACUTE URTICARIA AND ANGIOEDEMA

Physical exam:
sharply defined wheals, small-large,
erythematous/white with an
erythematous rim, round, oval,
acriform, anular, serpiginous →
confluence
Management :
- Prevention : elimination of etiol
- Histamin H1 blocker
- Prednisone