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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3113_Библиотеки_им_академика_М_И_Перельмана
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https://t.me/med1917
399
SKIN
Blisters (vesicles and bullae) 400
Erythema 402
Macules 405
Nodules 408
Papules 411
Purpura and petechiae 413
Pustules 416
Scales and plaques 418
Skinfold rash 421
NB: See also ‘Facial rash’ and ‘Facial ulcers and blisters’
in the ‘Face’ section and ‘Itching’ in the ‘General
physical’ section.
https://t.me/med1917
400
BLISTERS (VESICLES
AND BULLAE)
The GP overview
Blisters are skin swellings containing free uid. Up to 5 mm they are called vesicles, larger than
5 mm they are called bullae. e uid can be lymph, serum, extracellular uid or blood. Some
conditions cause both kinds of blister, but others mainly one or other type. Pustules are dealt
with elsewhere (see ‘Purpura and petechiae’).
Differential diagnosis
COMMON
trauma: skin friction, burns (thermal and chemical), insect bites
herpes simplex
herpes zoster
childhood viruses: hand, foot and mouth disease, chickenpox
eczema (pompholyx and other acute eczemas)
OCCASIONAL
pemphigus and pemphigoid
dermatitis herpetiformis
secondary to leg oedema (various causes)
bullous impetigo
drug reactions (e.g. ACE inhibitors, penicillamine, barbiturates)
erythema multiforme
RARE
pemphigoid (herpes) gestationis
porphyria
toxic epidermal necrolysis (Lyell’s syndrome)
epidermolysis bullosa
allergic vasculitis
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BLISTERS VESICLES AND BULLAE 401
Ready reckoner
Trauma Herpes simplex Herpes zoster Childhood viruses Eczema
Vesicles No Ye s Ye s Yes Possible
Bullae Ye s Possible Possible No Possible
Recurrent No Ye s No No Yes
Unilateral Possible Possible Ye s No Possible
Painful Ye s Ye s Ye s No Possible
Possible investigations
ere are unlikely to be any investigations that will prove useful in primary care. Usually, the
problem is either self-limiting or the cause obvious; in obscure cases, referral may result in skin
biopsy to establish the diagnosis. Patch testing may also be useful to identify possible allergens
in contact dermatitis, especially if occupational.
TOP TIPS
Herpes zoster involving the ophthalmic division of the trigeminal nerve will aect the eye
in about 50% of cases. e likelihood is increased if there are blisters on the side of the nose.
Ensure that the patient knows to seek help urgently if the eye becomes red or painful, or
there is blurring of vision.
In uncomplicated herpes zoster, explain the natural history of the condition to the patient,
resolving any worries (old wives’ tales abound) and warning about the possibility of
postherpetic neuralgia.
Follow up unexplained rashes. e bullae of pemphigoid, for example, may be preceded by
itching, erythema and urticaria by several weeks.
Herpes simplex and varicella zoster infections can become severe and disseminated in
the immunosuppressed – admit. Similarly, herpes simplex can result in a serious reaction
(Kaposi’s varicelliform eruption) in patients with atopic eczema.
Pregnant women with chickenpox are at signicant risk of severe varicella pneumonia; there
are also risks to the foetus. Follow the detailed guidance in the ‘Green Book’ (Immunisation
against Infectious Disease, Her Majesty’s Stationery Oce) when dealing with pregnant
women who have been in contact with chickenpox.
Toxic epidermal necrolysis (scalded skin syndrome) can develop rapidly in infants and
children, causing serious illness. Admit urgently if you suspect this diagnosis.
Pemphigus is a serious condition aecting a younger age group (usually middle-aged) than
pemphigoid. Inpatient care is usually required.
https://t.me/med1917
402
ERYTHEMA
The GP overview
Erythema is a reddening of the skin due to persistent dilation of supercial blood vessels, and
can be local or generalised. It is distinguished from ushing (see ‘Flushing’) by its permanence:
Flushing is transient.
Differential diagnosis
COMMON
cellulitis
gout
burns: thermal, chemical, sunburn
toxic erythema: drugs (e.g. antibiotics, NSAIDs), bacteria (e.g. scarlet fever), viruses
(e.g.measles, slapped cheek syndrome)
rosacea
OCCASIONAL
palmar erythema (e.g. pregnancy, liver disease, thyrotoxicosis)
phototoxic reaction to drugs (e.g. phenothiazines, tetracyclines, diuretics)
‘deck-chair legs’ (prolonged immobility)
erythema multiforme (various causes)
systemic lupus erythematosus (erythematous, photosensitive buttery rash)
erythema ab igne (reticulate pattern)
RARE
xed drug eruption
livedo reticularis: connective tissue disease
seroconversion rash of HIV
erythema nodosum: sarcoidosis, streptococci, tuberculosis, drugs
erythema induratum (Bazin’s disease: tuberculosis)
erythema chronicum migrans: Lyme disease
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ERYTHEMA 403
Ready reckoner
Cellulitis Gout Burns Toxic erythema Rosacea
Fever Ye s Possible No Possible No
Pustules No No No No Ye s
Periarticular Possible Yes Possible Possible No
Blisters Possible No Possible Possible No
Widespread No No Possible Ye s No
Possible investigations
LI KE LY: Uric acid (if possible gout).
POSSIBLE: FBC, ESR/CRP, LFT, TFT.
SMALL PRINT: Autoimmune studies, serology, CXR, ASO titre.
FBC/ESR/CRP: WCC and ESR/CRP raised in signicant infection; Hb may be reduced
(normochromic normocytic) in connective tissue disorder.
Autoimmune studies: If connective tissue disorder a possibility.
Serology: May help if suspect infective cause for eryt hema multiforme; also usefu l in assessing
immune status in a pregnant woman exposed to slapped cheek syndrome, and in diagnosis of
HIV infection and Lyme disease (though current guidance states that a diagnosis of Lyme
disease should be made clinically in patients with erythema migrans).
Uric acid: To conrm clinical suspicion of gout (when attack has subsided) especially if
considering allopurinol.
LFT, TFT: If palmar erythema present in non-pregnant patient – to detect alcohol excess
or hyperthyroidism.
Other investigations for erythema nodosum: If a non-drug cause is possible, investigations
likely to include CXR (for TB, sarcoidosis) and ASO titre (for streptococcal infection).
TOP TIPS
Toxic erythema caused by drugs tends to be itchy; if due to infection, it does not irritate but
is accompanied by fever.
Remember that there is oen a delay before a drug causes toxic erythema – therefore,
symptoms may only appear aer a course of treatment (especially antibiotics) has been
completed.
‘Deck-chair legs’ is erythema of the lower legs, sometimes with oedema and blistering, in the
immobile. It tends to be mistakenly diagnosed as persistent or recurrent cellulitis.
A violent local erythema, rapidly darkening and blistering and recurring at the same site,
suggests a xed drug eruption.
Remember to take a drug history, including over-the-counter medications. is may revea l the
underlying cause in toxic erythema, erythema nodosum and multiforme, and phototoxicity.
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404 SYMPTOM SORTER
Erythema nodosum and multiforme may be caused by signicant disease, including, very
occasionally, malignancy. If the patient is generally unwell or has other signicant symptoms,
investigate urgently or refer.
Take a travel history – lyme disease is endemic in forested areas. If not diagnosed and treated
early, it can have signicant complications.
Erythema multiforme with blistering and ulceration of the mucous membranes is Stevens–
Johnson syndrome. oug h rare, it is a very serious ill ness requiring urgent hospital treatment.
Enquire about joint symptoms – many causes of erythema (e.g. erythema multiforme,
buttery rash, livedo reticularis) can be linked to a connective tissue isorder.
Remember that parvovirus can cause serious problems in pregnancy – check serology in
women with suggestive symptoms, or exposure to a case.
NOTES:
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405
MACULES
The GP overview
A macule is a at, demarcated, abnormally coloured area of skin of any size. It may be red (e.g. drug
eruption), dark red (e.g. purpura), brown (e.g. a at mole) or white (e.g. pityriasis versicolor). Purpura
is described elsewhere (see ‘Purpura and petechiae’). ere is some crossover between erythema (see
‘Erythema’) and red macules.
Differential diagnosis
COMMON
drug reaction/allergy
at mole (junctional naevus)
non-specic viral exanthem
sun-induced freckles (including solar lentigines)
chloasma
OCCASIONAL
measles and rubella
post-inammatory hypo- or hyperpigmentation
café au lait spot (creamy brown) and Mongolian spot (brown or slate-grey)
Berloque dermatitis (brown: chemical photosensitisation, e.g. bergamot oil)
depigmentation: vitiligo, pityriasis versicolor, pityriasis alba
RARE
infections: macular syphilide, tuberculoid leprosy, typhoid (rose spots in 40%)
Albright’s syndrome
neurobromatosis (associated with more than six café au lait spots)
pathological freckles: Hutchinson’s freckle, Peutz–Jeghers syndrome
naevus anaemicus (permanent vasoconstriction due to neurovascular abnormality)
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406 SYMPTOM SORTER
Ready reckoner
Drug reaction Flat mole Viral Freckles Chloasma
Itching and burning Yes No No No No
Variable pigmentation No Ye s No Possible Possible
Red Ye s No Ye s No No
<
0.5 cm diameter
Possible Possible Possible Yes No
Symmetrical, muzzle area No No No No Ye s
Possible investigations
ere are very few relevant investigations to consider and they would be required only
exceptionally, as the diagnosis is usually clinical: Skin scrapings for mycology or uorescence
under Wood’s light may help in the diagnosis of pityriasis versicolor; acute and convalescent
serum samples may conrm rubella; serology for syphilis may be appropriate with an unusual
macular rash; and very occasionally, a skin biopsy may be required to clinch an obscure diagnosis.
TOP TIPS
A drug eruption can take 2 weeks to appear from the time of the rst dose – so don’t be
misled by the fact that a course of antibiotics may have been completed some days before the
related drug rash develops.
Pityriasis versicolor may be misdiagnosed as vitiligo. If in doubt, ta ke scrapings for mycology
or examine under Wood’s light.
Odd lines of hyperpigmentation on the sides of the neck are likely to be Berloque dermatitis – a
photosensitive rash caused by oil of bergamot, present in perfumes.
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MACULES 407
Hutchinson’s freckle is a giant, variegated freckle, seen in elderly sun-exposed skin. ere is
a high risk of malignant change, so refer.
Rubella is rare, but may become commoner as a result of media coverage of ‘immunisation
scares’. Establish whether or not a young woman presenting with a rubella-type rash is
pregnant – if she is, conrm her rubella status.
A child with very many freckles on and around the lips may have Peutz–Jeghers syndrome.
is is associated with small bowel polyposis.
Vitiligo tends to have a poor prognosis in Caucasians, especially if it is widespread and
aecting lips and extremities.
NOTES:
https://t.me/med1917
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