Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5230_Библиотеки_им_академика_М_И_Перельмана.pdf
Rash
2Worrying features RR >30, sats <92%, wheeze, systolic BP
<00mmHg, confusion, tachy/ bradycardia, rapidly changing, painful,
blistering, or non- blanchingrash.
Think about 2Life- threatening Meningococcal septicaemia (Fig.6.), nec-
rotizing fasciitis, TEN, SJS, urticaria (anaphylaxis), staphylococcal scalded
skin syndrome;
sles), shingles, erythema nodosum, erythema multiforme, vasculitis (eg
Henoch– Schönlein purpura).
tact), vasculitis, erythema ab igne, bullous disease (eg bullous pemphigoid
and pemphigus vulgaris).
Ask aboutSpeed of onset, distribution of rash, pain, associated symptoms,
exacerbating and relieving factors, family history;
joint/ GI disease, immunosuppression, weight loss;
cation, vaccinations, previous drugs to treat skin disease;
exposure to irritants, pets, exposure to others with illness/ skin disease.
Obs Temp, RR, BP, CRT, HR, O
Look at Hands and nails for pitting, Janeway lesions or Osler’s nodes, splinter
haemorrhages, and then examine aected area and fully expose rest of patient. Try to form a description of the lesions based upon size, shape, colour,
palpability, blisters, and associated features (E pp. 36–7). Also examine the
scalp, genitals, and mouth. Other examination as dictated by history.
Investigations BldsIf suspect infection or systemic disease; FBC, CRP,
ESR, U+E; blood cultures. Further investigation— Table6.2. See also
Table 6.3.
Table6.2 Investigating cutaneous eruptions
Test Use Example
Skin swab Viral PCR Herpes simplex
Blood test Autoantibodies Systemic lupus erythematosus
Nail clippings Fungal culture Onychomycosis
Patch testing Allergy testing Nickel allergy
Skin biopsy Culture Mycobacteria/ fungi
Skin scrapings Fungal culture Tinea
Skin swab Bacterial culture Impetigo
Wood’s light Fungal uorescence Erythrasma (skin folds)
Other acute Cellulitis, viral exanthem (eg chickenpox, mea-
Chronic Psoriasis, dermatitis (eg atopic, con-
PMH Previous skin disease,
DHAllergies, new medi-
SH Occupation,
sats.
2
Serology Guttate psoriasis
Histology TEN/ SJS
Immunouorescence Pemphigus/ pemphigoid
Microscopy Scabies
433RASH
434 CHAPTER6 Skin andeyes
Bacterial infections causingarash
Impetigo
$ Supercial epidermal infection typically seen around children’s faces.
SymptomsWeeping, spreading erythema, highly contagious.
Signs Erythema with yellow crust, serous discharge; occasionally blisters.
Investigations Skin swabsShow Staphylococcus aureus in >90% of cases, but
group Astreptococci (S.pyogenes) can befound.
Treatment Treatment of localized disease can be achieved with topical fusidic
acid/8h for wk. More extensive impetigo may require oral antibiotics, eg
ucloxacillin g/ 6h PO (for staphylococci) and phenoxymethylpenicillin 500mg/
6h PO (for streptococci). Ensure close contacts are examined and treated if necessary; encourage good hand hygiene and avoidance of sharing towels.
Erysipelas
$ Epidermal streptococcal infection with cutaneous lymphatic involvement.
Results in painful, well- demarcated erythema (±lymphadenopathy); typically seen on face orlegs.
Cellulitis
$ Non- necrotizing infection of the dermis.
Symptoms Hot, usually tender area of erythema, usually on leg
may be spreading; history of trauma to skin (insect bite, cannula site) or
tinea pedis. May have systemic eects:fever, anorexia, N+V, diarrhoea.
Signs Warm spreading erythema (outline area with marker to observe re-
sponse to treatment), ±mild oedema, break in the skin, serous discharge, can
develop blisters, lymphadenopathy in draining nodes, itemp, iHR,iRR.
Investigations blds iWCC and neutrophils, iCRP/ ESR; blood cul-
tures if pyrexial; D- dimer likely to be raised in infection so not useful
in dierentiating cellulitis fromDVT;
check multisite
MRSA swab; USS To exclude DVT (depending on Wells’
score E p. 508) or ruptured Baker’scyst.
TreatmentCheck local guidelines; likely organisms include S.aureus (may
be MRSA) or group Astreptococci (see also Box 6.):
• If patient is systemically well and has no other signicant
comorbidities, oral antibiotics (ucloxacillin g/ 6h PO; if MRSA
suspected or proven doxycycline 200mg STAT then 00mg/ 24hPO)
• If signs of systemic upset (itemp, iHR, iRR) or coexisting disease
(DM, IHD, PVD), admit for IV antibiotics (ucloxacillin g/ 6h IV; if
MRSA suspected or proven, vancomycin g/ 2hIV)
• 3Necrotizing fasciitis (E p. 435.) Very unwell, ‘out- of- proportion
skin pain’, rapidly spreading. Request senior help immediately
• 3Orbital cellulitis Painful or restricted eye movement, proptosis, or
visual disturbance.
K Box 6. Erythematous cannulasites
Cannulae should be dated and resited every 72h. If a cannula site is red
and inamed or pus is present, remove cannula, and clean and dress
the site. Give ucloxacillin g/ 6h PO or clarithromycin 500mg/ 2h PO
(if penicillin allergic) for 5d. Discuss with microbiology if MRSA+ve.
Bilateral cellulitis is very rare; consider an alternative diagnosis in those with both legs aected.
TreatmentAs for cellulitis.
Skin swabs Not usually helpful, but
or face;
3Necrotizing fasciitis (E OHAM4p. 497.)
SymptomsRapidly spreading painful erythema (pain disproportionate to
rash) with features of sepsis, fever, unwell, dGCS; may occur at break in
skin or operation site but often no apparent trauma.
Signs Rapidly spreading blanching erythema (outline with marker to ob-
serve spreading), blisters, ±oedema, lymphadenopathy in draining nodes,
sometimes crepitus over tissues (late sign), itemp, iHR, iRR,dBP.
Investigations blds iWCC and neutrophils, iCRP/ ESR, ilactate; Blood cul-
tures and skin swabs/ tissue aspirationMay identify infective organism(s) but
do not withhold treatment to do tests if patient is systemically unwell;
X- rayMay reveal gas in subcutaneous tissues of aectedarea.
Treatment 3This is a surgical emergency.
• Seek senior help
immediately (the moment you suspect, not once you
have watched the fasciitis evolve and conrm your suspicions)
• Surgical debridement is the most important measure,
surgeon withoutdelay
consult senior
• Likely to need combination of IV benzylpenicillin, gentamicin,
clindamycin, and metronidazole. Seek urgent microbiology advice.
Pathogens These may be a mixture of aerobic and anaerobic organ-
isms seen following abdominal surgery or in diabetics (type ), a group
AStreptococcus (type 2), or Clostridia (type 3— gas gangrene).
Outcome This depends upon speed of identication and initiation of
treatment, as well as comorbidity and the site aected. Extensive tissue
loss from surgery and necrosis is common; overall mortality is720%.
3
Meningococcal septicaemia (E OHCM1p. 806.)
Symptoms Fever, non- blanching (purpuric) rash (note, early rash may
blanch), joint and muscle ache, malaise; meningitis frequently occurs, reected by headache, neck stiness, and photophobia.
Signs itemp, iHR, iRR, cap rell >2s, dBP, non- blanching petechial or pur-
puric rash;
Investigations blds iWCC and neutrophils, iCRP/ ESR, meningococcal
PCR, deranged clotting if severe sepsis(DIC);
hold antibiotics before taking these if patient is unwell;
meningism/ photophobia if meningitis also present (Ep. 372).
Blood culturesDo not with-
CT headIdentify
any complications such as hydrocephalus or contraindications to LP;
LPWCC, Gram stain, MC+S, glucose, bacterial/viral PCR.
Treatment 3This is a medical emergency.
• Airway, Breathing (give O
• Seek help immediately— contact your seniors as soon as you suspect
), Circulation (obtain IV access)
2
• If patient is in shock (SBP <00mmHg), involve ICU team urgently
• 0.9% saline L STAT IV and goal- directed uid resuscitation (Ep. 485)
• Ceftriaxone 4g STAT IV withoutdelay
• Inform public health consultant once patient is stable.
Pathogen Neisseria meningitides, a Gram- negative diplococcus; since the
introduction of a vaccine for serogroup C, serogroup B accounts for the
majority of infections seen in Europe and North America.
Outcome This depends upon speed of identication and initiation of
treatment. Mortality for meningococcal septicaemia is about 0% in
the developed world. Complications in survivors include neurological
decits (eg cognitive impairment, deafness), limb amputation, renal
failure, and adrenal failure (Waterhouse– Friderichsen syndrome).
435BACTERIAL INFECTIONS CAUSING A RASH
436 CHAPTER6 Skin andeyes
Viral infections causingarash
Chickenpox (varicella zoster virus— VZV)(E OHCM1p. 400.)
Symptoms
Fever and malaise 4– 2d after exposure. Typical rash then develops: at
lesions, evolving to itchy scabs. Older children and adults at risk of development of
pneumonitis or encephalitis, manifesting as breathlessness or altered mental state.
Signs itemp, iHR, and presence of evolving rash; macules, papules,
vesicles, pustules, scabs, in centripetal distribution (spreading out from the
trunk). iRR and dO
ality, dGCS, or ataxia suggests CNS involvement. See Box 16.2.
Investigations
Serology
Viral antibody titres can be monitored but this is seldom necessary;
CXR
May show diuse consolidation in varicella pneumonitis;
other causes of neurology;
Treatment
Symptomatic: antipyretics and antihistamines. Antiviral therapy is
usually given to patients ≥4yr (aciclovir 800mg/ 5h PO). In the immunocompromised or those with complications (pneumonitis, encephalitis), use
aciclovir 0mg/ kg/ 8h IV. Consider ICU admission for respiratory support.
Pregnancy
Primary VZV infection during the st 20wk of pregnancy is associated with – 2% risk of foetal anomalies and spontaneous abortion; infection
within 5days of delivery is also associated with a risk of neonatal VZV infection. Women without a clear history of chickenpox should have viral specic
IgG titres checked and if negative, should be oered VZV vaccination before
becoming pregnant. The vaccine cannot be used in pregnancy, when primary
infection may require zoster immune globulin (ZIG) to prevent the onset of
disease, and oral aciclovir if the disease develops— discuss with microbiology.
K Box 6.2 Chickenpox
Uncommonly aects an individual more than once. Shingles Reactivation
of chickenpox virus; the virus lies dormant in the dorsal root/ cranial nerve
Non- immune individualsCan catch chickenpox from patients who have
ganglia;
either chickenpox or shingles; the infectious period runs from 48h prior to
onset of the rash until all lesions crustover.
sats suggest respiratory involvement. Altered person-
2
Not usually undertaken but
LP
Lymphocytic pleocytosis in viral encephalitis.
vesicular uid
can be sent for viral
CT brain
PCR
Exclude
;
Shingles (herpes zoster)
Symptoms Initially focal pain, followed by classical blistering rash in
a dermatomal distribution (will not cross the midline), ±malaise. If
multidermatomal, consider if patient immunocompromised.
Signs Erythematous papules, evolving into vesicles with pustules which crust
over after 77d. Usually thoracic or lumbar dermatome.
InvestigationsClinical diagnosis, but vesicular uid can be examined under
electron microscopy or sent for viral
TreatmentAntiviral therapy limits post- herpetic neuralgia and period of infect-
PCR.
ivity if started within 72h (valaciclovir g TDS 7days PO); parenteral antivirals
can be considered in immunocompromised (aciclovir 0mg/ kg/ 8h IV). Treat
pain with paracetamol, NSAIDs, and amitriptyline 25mg/ 24hPO.
•
Herpes zoster ophthalmicus Involvement of the ophthalmic branch of the
trigeminal nerve (CN Va); may lead to sight-threatening keratitis; apply
3% aciclovir ointment to eye/ 5h and
seek ophthalmic opinion
• Ramsay– Hunt syndrome (E OHCM1 p. 499.) Facial pain, vesicles in external
auditory canal and ipsilateral facial palsy; complete recovery in<50%.
Measles (rubeola)— notiable disease
Symptoms Prodrome of fever, coryza, and cough; rash spreading from
face and neck to trunk andlimbs.
Signs itemp, iHR, conjunctivitis, pathognomonic grey ‘Koplik’ spots
(rare to see!) on buccal mucosa seen 72d prior to maculopapularrash.
InvestigationsNone required routinely; measles serology in criticallyill.
TreatmentSupportive care; vitamin Asupplements if malnourished; compli-
cations include pneumonitis, pneumonia, encephalitis; subacute sclerosing
panencephalitis is a degenerative disease appearing 70yr post infection.
Rubella (German measles)— notiable disease
SymptomsRash with fever and coryza; adults may experience arthralgia.
SignsDiscrete macular rash spreading from face to trunk and limbs; features
of concurrent illness/ infection (itemp, iHR, etc); tender lymphadenopathy.
InvestigationsNone routine; blds iviral specic IgM during infection.
Treatment Supportive care; primary infection during st trimester of
pregnancy carries 790% foetal anomalies (eg deafness, cataracts).
Viral exanthema (the viralrash)
Symptoms Rash associated with prodromal symptoms of viral illness
(fever, myalgia, arthralgia, headache); may or may not beitchy.
Signs Widespread maculopapular rash; features of concurrent illness/
infection (itemp, iHR, pharyngitis, etc). Rash associated with numerous
viruses (echovirus, parvovirus, EBV, measles) so not diagnostic.
InvestigationsNone required routinely; discuss with virology if unwell.
TreatmentSimple analgesia; resolves over77d.
Fifth disease/ erythema infectiosum (‘slapped cheek’ fever)
SymptomsNon- itchy rash on cheeks, which feel burning hot; later spreads
to trunk and limbs; headache; otherwise well; usually in children.
Signs Erythematous rash on cheeks, and reticulate erythema (net- like
rash) on proximal limbs then trunk; caused by parvovirusB9.
InvestigationsNone required routinely.
TreatmentRash will subside over 7– 0d; treat concurrent symptoms.
Herpes simplex virus (cold sore/ genital herpes)
SymptomsSmall painful vesicles usually around mouth or in genitalarea.
SignsVesicles or pustules around mouth (usually HSV) or in genital area
(usually HSV2). Often resolve, but then return months or yearslater.
InvestigationsNot usually but vesicular uid can be sent for viralPCR.
Treatment This consists of aciclovir 200mg/ 5h or 400mg/ 8h PO for pri-
mary HSV infections and painful genital infections. Treat facial and genital
‘cold sores’ with aciclovir 5% to aected area/ 4h topically.
Molluscum contagiosum
Symptoms Small, non- itchy spots, occurring on trunk and limbs in child-
hood (skin contact) and around groin in early adulthood (sexual transmission); highly contagious.
SignsSmall translucent papules (– 3mm), which look uid- lled, but are
actually solid, often with the central depression (punctum). Caused by a
poxvirus, and usually resolve spontaneously after 6– 2mth.
InvestigationsNone routine; screen for other STDs in adults (Ep. 523).
TreatmentNone required, 5% potassium hydroxide can be used in older
children or adults.
437VIRAL INFECTIONS CAUSING A RASH
438 CHAPTER6 Skin andeyes
Fungal infections causingarash
Dermatophytes $ Pathogenic fungi, which cause a range of diseases.
Tinea corporis‘Ringworm’,mildly itchy, asymmetrical rash which spreads
with a slightly raised, scaly edge, often leaving a clear centre.
Tinea facieiDermatophyte infection of theface.
Tinea cruris Ringworm in the groin, though this lesion is often red and
more plaque- like with a well demarked border.
Tinea pedis‘Athlete’s foot’, is usually found in the webspaces of the toes, re-
sulting in itchy skin which is ssured and macerated. If found elsewhere on
the foot it is often more diuse and scaly, but just as itchy. Pustules canoccur.
Treatment Treatment of small focal areas of tinea can be achieved with
topical antifungals (terbinane, clotrimazole, miconazole, etc); more
widespread infections require oral therapy (terbinane, itraconazole).
Candida albicans $ Candida is a yeast, and thrives in warm moist areas, in
children’s nappies (nappy rash), in body folds (intertrigo), and also in interdigital webspaces, mimicking tineapedis.
The rash is erythematous with a ragged, peeling edge which may contains small pustules. The mouth and genital tract can also be aected and
present with small white plaques/ white discharge. Swab to conrm. Can
herald immunosuppression: is further investigation required?
Treatment Remove predisposing factors (ensure skin remains clean and
dry) and topical antifungal creams (clotrimazole); use drops (eg nystatin)
or pessaries (eg clotrimazole) for oral and genital tract infections respectively; resistant infections may require oral therapy (eg uconazole).
Infestations causingarash
Scabies $ This is an intensely itchy rash, often worse at night, caused
by the scabies mite, Sarcoptes scabiei.
Commoner in children and with social overcrowding (highly contagious).
The rash is papular and found in the interdigital webspaces of the hands
and feet, ankles, wrists, genitals, axillae, and umbilicus. Linear skin burrows are pathognomonic but not always present. Investigation: microscopic examination of skin scrapings/ dermoscopy looking formites.
Treatment Permethrin/ malathion:is only successful if the whole body is
treated, if all close contacts are treated and if bedding and clothing are
washed. Itching may last up to 4wk after treatment. Severe infection may
require PO treatment.
Lice These are blood- sucking parasites; Head lice(Pediculosis capitis) are
commonest in children, spread by direct contact and can result in scalp excoriation. The presence of eggs (‘nits’) in the hair conrms the diagnosis;
Body lice(Pediculosis corporis) are associated with poverty and not often seen
in the developed world; excoriations on the skin are often the onlysign;
(Phthiriasis pubis or ‘crabs’) are transmitted by sexual contact and com-
lice
monly aect coarse pubic hairs, but also leg, body, and facialhair.
Treatment Malathion/ permethrin (resistance common). Close contacts
should also be treated; clothing and bedding should be thoroughly washed
on high temperatures.
Pubic
Chronic inflammatoryrashes (E OHCSpp. 444–7.)
Recalcitrant, severe
eczema
Moderate to severe
eczema
Mild to moderate
eczema
Dry skin only
Step 4
Intensity of disease
Dermatitis (eczema) $ Found in 70% of the population in various forms:
• Atopic $ Onset usually in childhood; associated with asthma and allergies
•
Contact $ Type IV hypersensitivity (delayed); may blister
•
Venous eczema $ Seen in lower limbs of older patients with venousstasis
•
Seborrhoeic $ Greasy scaling of scalp/ central face, associated with
reaction to skinyeast.
Symptoms These include itchy, dry skin, or patches of infected skin.
Signs Ill- dened erythematous patches with excoriations. Typically aect
the exures of the elbow, knees, and around the neck; vesicles and serous
weeping (infected). Superimposed bacterial or viral infections are common.
Chronic lichenication and hyperpigmentation can develop.
Treatment This is multifactorial and depends on underlying cause. Attempt iden-
tication and avoidance of known irritants/ allergens. In atopic eczema, triple
therapy with topical steroids (E p. 76), topical emollients, and bath oil and
soap substitutes form the mainstay; step 4 treatments such as UVB/ PUVA,
ciclosporin, methotrexate, azathioprine may be prescribed by a dermatologist
(Fig.6.2). Treat bacterial superinfection promptly, eg ucloxacillin g/ 6hPO.
Systemic therapy (eg ciclosporin)
Step 3
Step 2
Low-mid potency topical corticosteroids
Step 1
skin hydration, emollients, avoidance of irritants,
identication and addressing of specic trigger factors
Fig.6.2 Step- wise management of atopic eczema. † Calcineurin inhibitors
include pimecrolimus (Elidel
Reproduced from J Allergy Clin Immunol, 8, Akdis, C.A. etal., Diagnosis and
treatment of atopic dermatitis in children and adults, 52– 69. © 2006, with permission from Elsevier. Available free at Mwww.jacionline.org
®
) and tacrolimus (Protopic®).
Psoriasis$ Inammation of the dermis, with epidermal hyperproliferation.
Occurs in 72% of the population, with peak incidences in the early 20s and 50s.
Exacerbations can be precipitated by infections, drugs (eg lithium, β- blockers),
UV light, alcohol, and stress.
Symptoms Itchy, dry patches of skin which can
bleed when scratched. Joint pain, swelling, and stiness (arthritis can precede
skin involvement);
Signs Chronic plaque psoriasis
plaques, especially on the extensor surfaces of elbows and knees, lower back, and
scalp; nail pitting;
and soles;
throat infection, causing numerous small pink papules/ plaques on the trunk;
Flexural psoriasis
Emollients, mild to moderate steroids, vitamin D analogues, and retinoids are
common topical treatments. UVB/ PUVA, methotrexate, ciclosporin, anti- TNF/
other biologic therapies, especially if associated psoriatic arthritis (Ep. 514).
2
NICE clinical knowledge summary available at Mhttps://cks.nice.org.uk/topics/eczema-atopic/
3
NICE psoriasis guidelines available at Mguidance.nice.org.uk/ CG53
Pustular psoriasis can be generalized (emergency)
Guttate psoriasis
Occurs acutely, often 2– 3wk after a streptococcal
Tends to occur in later life, and forms in exures;
or UV therapy
Basic treatment
Well- dened pink/ red scaly
treatment
Continue topical
Continue basic treatment
Aects palms
Treatment
439CHRONIC INFLAMMATORYRASHES
2
3
440 CHAPTER6 Skin andeyes
Other causes ofrash
Urticaria (Hives or ‘nettle rash’.) Characterized by the formation of in-
tensely pruritic papules or plaques (‘weal’) which are pale initially but become
erythematous with a surrounding rim of pale skin or erythema (‘are’). Acute
(<6wk):common in response to certain topical chemicals (eg nettle sting) but
also in response to systemic drugs (sometimes part of anaphylaxis), antigens
(eg blood transfusion), or virus. Chronic (>6wk)— well patient, uctuating
urticarial rash, cause often unknown. Treat with antihistamines.
Erythema nodosum Characterized by tender, erythematous nodules
or plaques, typically on the shins. Commoner causes: infections (streptococcal (commonest), Mycoplasma pneumoniae, TB, and EBV), sarcoidosis,
inammatory bowel disease (IBD), autoimmune disorders, pregnancy, and
drugs (sulfonamides and the oral contraceptive pill) (E OHCS1p. 451).
Erythema multiforme This is a hypersensitivity rash and has two sub-
types.
Erythema multiforme minor Produces ‘target’ lesions, with a red centre,
a clear circular area, and an outer redring.
rash with involvement of one or more mucous membranes (classically the
mouth). Often no precipitant is identied (750%) but associations are recognized with several infections (eg HSV, adenovirus, Mycoplasma pneumoniae)
and drugs (eg sulfonamides, NSAIDs, penicillins) (E OHCS1p. 451).
SJS and 3TEN These represent dierent extents of severe, life-
threatening skin inammation that is usually drug induced. Widespread
blisters, with skin shedding, erythematous macules, and mucosal erosions
aect <0% body surface area (SJS) or >30% (TEN) with an overlap diagnosis in between. Mortality is high. Dermatology review and senior help
should be sought immediately, with close attention to skin care, uid replacement, and prevention of superinfection (E OHCS1p. 451).
Pemphigus and pemphigoid These are rare primary blistering diseases.
Pemphigus causes supercial blisters and often involves the mucous membranes of the mouth; the blisters are delicate and burst easily, so areas of raw
skin are often more noticeable than blisters. Pemphigoid causes tense blisters
in older patients, and seldom aects the mouth. Both are autoimmune and
require dermatology input. Can be life- threatening (E OHCS1p. 452).
Pyoderma gangrenosum This presents with painful nodules or pus-
tules which often ulcerate, leaving an undermined ulcer with a dusky
purple edge. Associated with IBD, primary biliary cirrhosis, and rheumatoid arthritis among others, the exact cause remains unclear. Needs urgent
dermatology assessment (E OHCS1p. 452).
Henoch– Schönlein purpuraLargely self- limiting small vessel vascu-
litis typically seen following a simple upper respiratory tract infection in
childhood. Petechiae and purpura develop on the legs and buttocks. May
have associated abdominal pain, arthralgia, and oedema (E OHCS1
p. 241). Must check renal function and dipurine.
Granuloma annulareCommon, benign inammatory disorder of un-
clear aetiology, characterized by clusters of rm papules appearing on the
hands, feet, or trunk which later merge into a ring. Associations include
TDM, but most cases appear in well patients (E OHCS1p. 436).
Erythema multiforme majorA similar
Table6.3 Common skin manifestations insystemic disease
Diabetes mellitus
(E pp. 342–4)
Coeliac disease
(E p. 322)
IBD (E p. 323)
Rheumatoid arthritis
(E p. 512)
SLE (E p. 515)
Hyperthyroidism
(E p. 348)
Hypothyroidism
(E p. 349)
Neoplasia Acanthosis nigricans (velvety, brown pigmented plaques,
Drug eruptions
(E OHCS1 p. 451)
Vasculitis Palpable purpuric rash typically on shins; wide range of
HIV
(E p. 494)
Candidiasis, necrobiosis lipoidica (yellow maculopapular
lesions on the shins, can ulcerate), skin infections
(cellulitis)
Dermatitis herpetiformis (intensely itchy papules and
vesicles on knees, elbows, back, and buttocks)
Erythema nodosum, pyoderma gangrenosum
Rheumatoid nodules (rm nodules either loose or
attached to deep structures over extensor surfaces,
classically the elbows), vasculitis, pyoderma gangrenosum
Facial buttery rash, photosensitivity, red scaly rashes,
diuse alopecia (hair loss)
Pre- tibial myxoedema (non- pitting plaques and nodules,
classically on the shins), clubbing, alopecia
Sparse coarse hair, dry skin, asteatotic eczema (pruritic,
dry, cracked skin)
often around the neck), dermatomyositis, ichthyosis
(scaly skin), pruritus
Maculopapular rash (±fever and eosinophilia); urticaria;
erythema multiforme, SJS/ TEN
other pathologies including telangiectasia, urticaria, ulcers
(E p. 621 for autoantibodies in diagnosis)
Infections (oropharyngeal candida, facial/ genital
molluscum contagiosum, herpes simplex, varicella
zoster E p. 436); seborrhoeic dermatitis or psoriasis
(Ep.439); Kaposi sarcoma (enlarging purple patches or
plaques seen on feet, arms, legs, or oral mucosa)
441OTHER CAUSES OF RASH
442 CHAPTER6 Skin andeyes
Skinlumps
2Worrying features Weight loss, night sweats, hard irregular
lump,isize.
Think about 2Serious Skin cancer, sarcoma, lymphoma, TB;
CommonLipoma, epidermoid cyst, abscess, boil, carbuncle, ganglion, -
broma, lymph node, naevi, skin tags, keratoacanthoma, keloid scarring,
tissued cannula (Box 6.5).
Ask aboutLocation, speed, and duration of onset, change with time,
pain, other lumps, trauma, bites, infections, skin changes, systemic symptoms (eg weight loss, vomiting, fever);
radiotherapy; immunosuppression;
cupation;
FHSkin cancer.
Look for Site, size, shape, consistency (hard, rm, soft, uctuant), ten-
derness, temperature, surface, association with skin (moves with skin—
intradermal, skin moves over it— subcutaneous), overlying skin (colour,
punctum, ulcerated), edges, mobility/ tethering, pulsatility, transillumination, relationship to nearby structures, lymphadenopathy, splenomegaly.
Investigations bldsConsider FBC, U+E, LFT, CRP,ESR; Imaging CXR,
USS, CT/ MRI;
BiopsyFNA, punch biopsy, excision biopsy.
Lipoma $ Common, benign tumour of mature fatcells.
Symptoms Single or multiple, non- painful, can cause pressure eects,
common on the trunk and neck, never found on palms/ soles offeet.
SignsSmooth, well- dened, soft, subcutaneous, mobile, no skin changes.
ManagementLipoma can be surgically excised if causing distress.
Epidermoid cyst $ Proliferation of epidermal cells within dermis.
Symptoms Single or multiple, painful if infected, common on the trunk,
neck and face, almost never found on palms/ soles offeet.
Signs Firm, well- dened, intradermal, mobile; overlying punctum is
common; may discharge white/ cheesy material; can become inamed.
Management No treatment. Consider ucloxacillin 500mg/ 6h PO if in-
amed/ tender, may also require incision and drainage; surgical excision
once non- inamed.
Ganglion cyst $ Cystic lesion of joint or synovial sheath of tendon.
SymptomsSingle, non- painful; 80% occur atwrist.
SignsSmooth, well dened, subcutaneous, transilluminable.
ManagementConservative; can be aspirated or excised, but 740%recur.
Fibroma $ Benign tumour of connective tissue; can occur in anyorgan.
Symptoms and signs These vary according to tissue aected, usually slow
growing with no overlying skin changes.
ManagementBiopsy/ imaging if any doubt; excision often possible.
Sarcoma $ Rare, but devastating malignant tumour of connective tissue.
SymptomsSingle, painful, progressive enlargement, weightloss.
SignsFirm/ hard, tethered, regional lymphadenopathy.
ManagementCombination of surgery, radiotherapy, and chemotherapy.
PMH Previous lumps, cancer,
SHForeign travel, sun exposure, oc-