Rash

 HAP28 - rash - only really covers erythroderma! 

Erythroderma is skin redness over lots of the body. It could be caused by anything but is really itchy. You need emollients, consider steroids and discuss with dermatology. 

Idiopathic erythroderma is is sometimes called 'the red man syndrome'.

✓Generalized erythema and edema affects 90% or more of the skin surface.
✓Warm and itchy skin noted
✓Eyelid swelling may result in ectropion.
✓scaling begins 2 to 6 days after onset of a erythema. pic.twitter.com/QgzwUr4skB

— ERresidentsquad (@Erresidentsquad) January 5, 2021

Psoriatic erythroderma

Most common cause of erythroderma is exacerbation of an underlying skin disease, such as psoriasis, contact dermatitis, seborrheic dermatitis, lichen planus, pityriasis rubra pilaris, HIV or a drug reaction, such as the use of topical steroids.#FOAMed pic.twitter.com/4HgzxcC00w

— ERresidentsquad (@Erresidentsquad) January 5, 2021

https://www.rcemlearning.co.uk/modules/a-spot-diagnosis/ https://www.rcemlearning.co.uk/modules/psor-throat/
https://www.rcemlearning.co.uk/modules/tired-purple-legs/
https://www.rcemlearning.co.uk/foamed/meningitis/
https://www.rcemlearning.co.uk/modules/dermatological-examination/
https://www.rcemlearning.co.uk/modules/simply-red-rash-decisions-in-resus/
https://www.rcemlearning.co.uk/foamed/7-pem-rashes/
https://www.rcemlearning.co.uk/modules/a-minor-rash-but-with-titanic-implications/
https://www.rcemlearning.co.uk/modules/living-a-rash-hand-to-mouth-existence/
https://www.rcemlearning.co.uk/modules/crash-and-burn/
https://www.rcemlearning.co.uk/reference/common-childhood-exanthems/
https://www.rcemlearning.co.uk/modules/a-spotty-boy/
https://www.rcemlearning.co.uk/modules/a-spot-diagnosis/ https://www.rcemlearning.co.uk/modules/feeling-hot-hot-hot/ https://www.rcemlearning.co.uk/modules/a-spotty-boy/
http://www.pcds.org.uk/clinical-guidance/erythroderma
https://www.rcgp.org.uk/dermatologytoolkit

Erysipelas

Part of a spectrum of infection.

1. Impetigo - see http://adultemergencymedicine.blogspot.com/2018/08/rashes-impetigo.html 

2. Erysipelas is a superficial cellulitis, with similar risk factors. It looks a lot worse than cellulitis with ruptured bullae and vivid bright red erythema. Almost all erysipelas is caused by group A beta haemolytic strep. It can recur due to persistence of risk factors and lymphatic drainage. Complications can include abscesses, gangrene, chronic leg swelling

Signs and symptoms are normally abrupt, affecting predominantly the lower limb and face. It has a sharp raised border, and is bright red and swollen. The swelling may lead to dimpling, blistering, and even necrosis.

3. Cellulitis
Cellulitis is very rarely bilateral. 35-50% of patients will have a leukocytosis, 60-92% will have an elevated ESR, and 75-95% will have an elevated CRP.  Blood cultures are unlikely to be helpful.
Orals are very bioavailable so most of the time are just as good as IVs.

Often caused by strep and staph. Atypicals are common: Cat bites can have pasteurella, sea water Vibrio vulnificus, fresh water Aeromonas hydrophila, fish farms Streptococcus iniae. These atypicals can cause a rapidly progressive cellulitis.

Fascitis necrotizante

Todo el crédito para el genial Jorge Muniz (@medcomic)
Visita su página en https://t.co/XtlgPxqn2Y pic.twitter.com/B7bOQA18IL

— Doc Fico (@DocFico) March 15, 2017

Class I: No signs of systemic toxicity or co-morbidities. Can be managed on POs.
Class II: 2 or more SIRS, but no organ dysfunction, or have a co-morbidity. May need IV outpatient management.
Class III: Sepsis and organ dysfunction, or unstable co-morbidities normally require admission.
Class IV: Severe life threatening infection.

4. Necrotising Fascitis

https://www.dermnetnz.org/topics/erysipelas/
https://journalfeed.org/article-a-day/2018/lrinec-score-physical-exam-or-imaging-for-necrotizing-infection
http://www.emdocs.net/cellulitis-mimics-ed-considerations/
https://first10em.com/cellulitis-antibiotics/
https://www.rcemlearning.co.uk/modules/cellulitis-and-other-skin-infections/
https://journalfeed.org/article-a-day/2018/is-a-blood-culture-needed-in-cellulitis
https://www.rcemlearning.co.uk/references/cellulitis/
http://www.tamingthesru.com/blog/2018/9/3/necrotizing-fasciitis-and-the-spectrum-of-soft-tissue-infections

Rashes - impetigo

Impetigo is a superficial infection of the epidermis caused by Staphylococcus aureus, group A beta-haemolytic streptococci or maybe even MRSA. Children should stay away from school until lesions are crusted and healed, or 48 hours after commencing antibiotic treatment. Several clinical forms of impetigo exist. 1. Non-bullous impetigo is the usual form. Red macules form initially, then golden crusts. It is itchy but not painful. Regional lymphadenopathy is common. 2. Bullous impetigo. Here there is sloughing of the epidermis due to toxin production. Vesicles/bullae may be on face, buttocks, nappy area or trunk. Inpatient care is required for infants with bullous impetigo and patients with widespread impetigenised dermatitis who may develop sepsis or dehydration.

What are the 3 types of impetigo? #RoshQuiz #FOAMed #FMRevolution #NursePractitioner #PANCE #PEM #PedsEM pic.twitter.com/94jnKr07ga

— Rosh Review's Adam Rosh (@RoshReview) June 15, 2017

Treatment: 1. use mupirocin nasal ointment to eradicate nasal carriage when treating impetigo on the face 2. Remove the scab, and then apply local treatment - fucidin and bactroban 3. Systemic if that fails 4. Remember not to go to school 5. Excellent hygiene

Impetigo. Local treatment first. Fucidin and bactroban. Not to school or nursery for 48 hours. #foamed

— South London EM FOAM (@slemfoam) October 16, 2014

References https://wikem.org/wiki/Impetigo https://www.rcemlearning.co.uk/references/cellulitis/ http://www.publichealth.hscni.net/sites/default/files/Guidance_on_infection_control_in%20schools_poster.pdf https://www.summitmedicalgroup.com/library/pediatric_health/hhg_impetigo/ http://www.bad.org.uk/for-the-public/patient-information-leaflets/impetigo/?showmore=1&returnlink=http%3A%2F%2Fwww.bad.org.uk%2Ffor-the-public%2Fpatient-information-leaflets#.W4g8xehKjIU