Table Of ContentA Colour Handbook
Acute Adult
Dermatology:
Diagnosis and Management
Daniel Creamer
Consultant Dermatologist, King’s College Hospital, London, UK
Jonathan Barker
Professor of Clinical Dermatology, St. John’s Institute of Dermatology,
King’s College, London, UK
Francisco A Kerdel
Voluntary Professor and Director of Inpatient Dermatology,
University of Miami Hospital, Miami, Florida, USA
MANSON
PUBLISHING
Dedication
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Copyright © 2011 Manson Publishing Ltd
ISBN: 978-1-84076-102-3
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Other Manson titles that may be of interest:
Chan:Blistering Skin Diseases
Elston:Infectious Diseases of the Skin
Ferguson & Dover: Photodermatology
Menter & Stoff: Psoriasis
Rycroft, Robertson & Wakelin: Dermatology, A Colour Handbook, 2nd edition
Sheridan:Burns –A Practical Approach
CONTENTS
Preface . . . . . . . . . . . . . . . .5 CHAPTER 6 Hidradenitis suppurativa . . .122
Acknowledgements . . . . . .6 Blistering diseases . . . . . . .65 Acne conglobata and acne
fulminans . . . . . . . . . . .124
Contributors . . . . . . . . . . . .6 Bullous pemphigoid . . . . . .66
Erysipelas and cellulitis . . . .126
Pemphigus vulgaris and
CHAPTER I pemphigus foliaceous . . .68 Necrotizing fasciitis . . . . . .128
Eczema . . . . . . . . . . . . . . . . .7 Dermatitis herpetiformis . . .72 Septic vasculitis
Atopic dermatitis . . . . . . . . . .8 Epidermolysis bullosa and infectious purpura
fulminans . . . . . . . . . . .130
Eczema herpeticum . . . . . . .10 acquisita . . . . . . . . . . . .74
Lyme disease . . . . . . . . . . .132
Pompholyx eczema . . . . . . . .12 Linear IgA bullous
dermatosis . . . . . . . . . . .76 Toxic shock syndrome and
Discoid eczema . . . . . . . . . .14
staphylococcal scalded
Porphyria cutanea tarda . . . .78
Venous eczema . . . . . . . . . . .16 skin syndrome . . . . . . . .134
Allergic and irritant contact Syphilis . . . . . . . . . . . . . . . .136
CHAPTER 7
dermatitis . . . . . . . . . . . .18
Vascular diseases . . . . . . . .81
Seborrhoeic dermatitis . . . . .20 CHAPTER 11
Small vessel vasculitis . . . . . .82
Chronic actinic dermatitis . . .22 Viral diseases . . . . . . . . . .139
Polyarteritis nodosa . . . . . . .84
Viral exanthem . . . . . . . . . .140
CHAPTER 2 Cutaneous embolism . . . . . .86
Herpes simplex . . . . . . . . . .142
Psoriasis . . . . . . . . . . . . . . .25 Widespread cutaneous
Erythema multiforme . . . . .144
necrosis . . . . . . . . . . . . . .88
Guttate psoriasis . . . . . . . . . .26
Chickenpox (varicella) . . . .146
Calciphylaxis . . . . . . . . . . . . .90
Plaque psoriasis . . . . . . . . . .28
Herpes zoster (shingles) . . .148
Pyoderma gangrenosum . . . .92
Palmo-plantar pustulosis . . . .30
Orf . . . . . . . . . . . . . . . . . . .151
Sweet’s syndrome . . . . . . . . .94
Generalized pustular
psoriasis . . . . . . . . . . . . . .32 Dependency syndrome . . . . .96 CHAPTER 12
Fungal diseases . . . . . . . .153
CHAPTER 3 CHAPTER 8
Tinea (dermatophyte
Papular and papulo- Panniculitis . . . . . . . . . . . . .99
infections) . . . . . . . . . . .154
squamous dermatoses . . .35
Erythema nodosum . . . . . .100
Candidiasis . . . . . . . . . . . . .158
Lichen planus . . . . . . . . . . . .36 Panniculitis . . . . . . . . . . . . .102
Pityriasis rosea . . . . . . . . . . .38 CHAPTER 13
Pityriasis rubra pilaris . . . . . .40 CHAPTER 9 Dermatoses caused by
Pityriasis lichenoides acuta . .42 Connective tissue arthropods . . . . . . . . . . . .161
disease . . . . . . . . . . . . . . .105
Eruptive xanthomata . . . . . .44 Scabies . . . . . . . . . . . . . . . .162
Discoid lupus
Sarcoidosis . . . . . . . . . . . . . .46 Insect bites . . . . . . . . . . . . .164
erythematosus . . . . . . .106
Darier’s disease . . . . . . . . . . .48 Pediculosis (lice) . . . . . . . . .166
Systemic lupus
Grover’s disease . . . . . . . . . .50 erythematosus . . . . . . . .108
CHAPTER 14
Subacute cutaneous lupus
CHAPTER 4 erythematosus . . . . . . . .110 Travellers’ and tropical
dermatoses . . . . . . . . . . . .169
Erythroderma . . . . . . . . . .51 Adult-onset Still’s disease . .112
Cutaneous larva migrans . .170
Dermatomyositis . . . . . . . .114
CHAPTER 5 Furuncular myiasis . . . . . . .171
Urticaria . . . . . . . . . . . . . . .55 CHAPTER 10 Tungiasis . . . . . . . . . . . . . .172
Acute urticaria . . . . . . . . . . .56 Bacterial diseases . . . . . . .117 Leishmaniasis . . . . . . . . . . .173
Angio-oedema . . . . . . . . . . .58 Impetigo . . . . . . . . . . . . . .118 Onchocerciasis . . . . . . . . . .174
The physical urticarias . . . . . .60 Folliculitis and Sporotrichosis . . . . . . . . . . .176
Urticarial vasculitis . . . . . . . .62 furunculosis . . . . . . . . .120 Rickettsial spotted fevers . . .177
Dengue . . . . . . . . . . . . . . .178 Polymorphic light eruption . .208 Abbreviations . . . . . . . . .235
Swimmer’s itch . . . . . . . . . .180 Phytophotodermatitis . . . . .210
Sea-bathers’ eruption . . . . .181 Recommended reading .236
CHAPTER 17
Jellyfish stings . . . . . . . . . . .182
Pregnancy dermatoses . .211 Index . . . . . . . . . . . . . . . . .237
CHAPTER 15 Polymorphic eruption of
Tumours and pregnancy . . . . . . . . . . .212
malignancies . . . . . . . . . .185 Pemphigoid gestationis . . . .214
Malignant melanoma . . . . .186
CHAPTER 18
Squamous cell carcinoma . .188
Drug- and therapy-induced
Pyogenic granuloma . . . . . .191
dermatoses . . . . . . . . . . . .217
Kaposi’s sarcoma . . . . . . . .192
Acute graft-versus-host
Mycosis fungoides and disease . . . . . . . . . . . . . .218
Sézary syndrome . . . . . .194
Drug-induced exanthem . .220
Primary cutaneous B cell
Phototoxic drug eruption . .222
lymphoma . . . . . . . . . . .196
Drug reaction with eosinophilia
Cutaneous metastases . . . . .198
and systemic symptoms . .224
CHAPTER 16 Acute generalized
exanthematous
Environmental and
pustulosis . . . . . . . . . . .226
physical dermatoses . . . .201
Fixed drug eruption . . . . . .228
Chilblains . . . . . . . . . . . . . .202
Stevens–Johnson
Miliaria . . . . . . . . . . . . . . . .204 syndrome/toxic
Minor burns . . . . . . . . . . . .205 epidermal necrolysis . . .230
Dermatitis artefacta . . . . . .206
PREFACE
5
It is sometimes reckoned, by the ill-informed, information as well as encouraging a structured
that skin disease does not present acutely. This and thorough approach to the patient with an
is quite untrue. A significant proportion of skin acute dermatosis.
disease develops rapidly, is highly symptomatic, The sections have been written so that
and can be associated with considerable essential information about each disorder is
morbidity. While most patients with acute skin summarized in a clear and concise way. After a
disorders are initially seen by primary care brief introduction, there is a description of the
services, ‘hot’ cases are also encountered in clinical features, followed by a differential
hospital emergency departments, and, of diagnosis, a list of important complic ations,
course, in dermatology clinics. However, for and the relevant investigations. Treatment is
many of the clinicians who provide front-line divided into two sections, the first outlines
medical care there is a relative lack of training the immediate action plan and the second
in acute dermatology. This book aims to help highlights long-term management considera-
meet that need. tions. Each condition described is illustrated by
In drawing up a list of conditions covered in clinical pictures.
this book two major criteria have been used: It is hoped that this book will enable all
firstly, those dermatoses which are character- medical staff seeing patients with acute skin
ized by a sudden onset and rapid progression, problems to practise more effectively. It is
and, secondly, diseases of the skin which are aimed at dermatologists in training, primary
associated with significant local or systemic care physicians, dermatology nurse specialists,
morbidity. The disorders presented include all and emergency department staff. It should also
the common inflammatory and infective appeal to the general physician who is
dermatoses as well as a number of rarer con - interested in dermatology.
ditions. There are also sections on tumours, Finally, as stated in the title, this is a book
connective tissue diseases, travellers’ derma- concerning adult skin disease. Although there
toses, drug eruptions, and rashes caused by is some overlap, acute dermatoses in neonates,
environmental and physical factors. infants, and children have a different clinical
The presentation of a patient with an acute spectrum and often present in a contrasting
medical problem compels the clinician to way to adults. There is also a distinct approach
supply an accurate diagnosis and an effective to therapy in paediatric dermatology. These
management plan quickly and efficiently. This differences highlight the need for a separate
demand is challenging in any branch of book covering children’s dermatoses and, at
medicine. In the context of dermatology the the time of writing, a companion volume
clinician requires an ability to assess skin signs entitledAcute Paediatric Dermatology –A Colour
correctly coupled to a broad understanding of Handbookis in development.
cutaneous disease and therapeutics. To optim-
ize the consultation these virtues must be allied Daniel Creamer
to a methodical clinical technique. Hopefully Jonathan Barker
this book will provide a useful source of Francisco A Kerdel
ACKNOWLEDGEMENTS
6
In writing this book I owe a great debt to my John’s Institute of Dermatology. I would like
consultant colleagues, both past and present, in to thank the photographers from both
the department of dermatology at King’s departments for the superlative quality of their
College Hospital, London; Dr Saqib Bashir, work. In particular I wish to thank Miss Lucy
DrAnthony du Vivier, Dr Claire Fuller, Prof Wallace for her unflagging kindness in collating
Rod Hay, Dr Elisabeth Higgins, Dr Sarah the images from King’s. I also owe a special
Macfarlane, and Dr Rachael Morris-Jones. debt to Mr Stuart Robertson of the St John’s
Ihave been lucky enough to benefit from their Institute of Dermatology who has given his
clinical experience and it is a pleasure to record time and expertise so generously in the
my appreciation and thanks. It has also been selection and preparation of all the pictures
my good fortune to collaborate with other used. A few photographs have come from other
colleagues on aspects of acute skin disease, and sources and I wish to acknowledge the
in particular I wish to acknowledge the help generosity of the following; Dr Lindsay
Iobtained from Sister Judy Davids, Dr Patrick Whittam, Dr Manuraj Singh, Dr Andrew
Gordon, Dr Nick Craven, and Mr Gregory Pembroke, Mr Gregory Williams, Dr Sheena
Williams. Allan, Dr Ruth MacSween.
I would like to thank Prof Neil Cox who An educational grant from Leo Pharma
reviewed the manuscript and gave me some helped towards preparing the book images and
extremely helpful advice as I was flagging on I am extremely grateful to them for supporting
the last lap. this project.
The clinical images for this book have been Finally it is a pleasure to acknowledge the
supplied by the departments of medical unfailing help and extreme patience of Ms Jill
photography at King’s College Hospital and St Northcott of Manson Publishing.
CONTRIBUTORS
The following doctors contributed sections to the book while they were undertaking their training
in dermatology:
Karim Amin, Saqib Bashir, Emma Benton, Lesley-Ann Murphy, Jana Natkunarajah,
Samantha Bunting, Ai-Lean Chew, Nuala O’Donoghue, Guy Perera, Laura
Emma Craythorne, Simon Dawe, Proudfoot, Sandrine Reynaert, James Shelley,
Paul Farrant, Sacha Goolamali, Kate Short, Karen Watson, Jonathan White,
Justine Hextall, Sharon Jacobs, Juliet Williams, Sharon Wong, Tracey Wong.
Sarah Macfarlane, Claire Martyn-Simmons,
CHAPTER 1
7
Eczema
Atopic Venous
dermatitis eczema
Eczema Allergic and
herpeticum irritant contact
dermatitis
Pompholyx Seborrhoeic
eczema dermatitis
Discoid Chronic
eczema actinic
dermatitis
8 CHAPTER 1 Eczema
Atopic dermatitis 1
In atopic dermatitis (AD) the skin is chronically
dry and itchy but also susceptible to inter-
mittent inflammatory exacerbations. An acute
flare of AD is characterized by worsening
pruritus and active skin inflammation which, if
untreated, can involve the whole skin. A
number of factors can precipitate an exacer-
bation of AD, including temperature changes
(central heating), strong sunlight (in some
individuals, in others summer sunshine is
helpful), common allergens (house dust mite,
animal dander), and pregnancy. Secondary
staphylococcal skin infection commonly com -
plicates acute AD and, indeed, may be the trig- 1Atopic dermatitis. This patient’s skin was
ger for a sudden deterioration in previously well intensely itchy. There are numerous excoriated
controlled eczema. papules on a background of patchy erythema.
CLINICAL FEATURES
Examination of active AD reveals areas of 2 2Atopic
poorly defined erythema, inflammatory dermatitis. Fixed
papules, and fine scaling (1). The sites of erythema is a
predilection are the face, neck, limb flexures, sign of active AD.
and hands (2). When very active the erythema Flexural surfaces
of AD is urticated and can rapidly spread to are commonly
involve the whole skin (3). The intense itch involved.
leads to scratching which results in linear
scratch marks and excoriated papules (4). White
dermo graphism describes pale streaks from
scratching within areas of erythema. Unlike
other forms of acute dermatitis, vesicles do not
occur in activeAD, however a serous exudate
and crusting may be present. Secondary
bacterial infection with Staphylococcus aureus
causes a honey-coloured discolouration to the
scale (impetiginization) (5). Patients with long-
standing AD also display the signs of chronic 3
eczema, such as lichenification.
DIFFERENTIAL DIAGNOSIS
• Seborrhoeic dermatitis (p. 20, erythema
and scaling of the face, scalp, and chest).
• Contact dermatitis (p. 18, eczema in a
localized area or unusual distribution).
• Eczema herpeticum (p. 10, eczema plus
small, punched-out erosions of herpes
simplex virus (HSV) infection).
• Scabies infestation (p. 162, severe pruritus
plus burrows at the wrists and finger
webs).
3Atopic dermatitis. An acute flare of AD can
result in extensive areas of urticated erythema.
Atopic dermatitis 9
COMPLICATIONS Systemic therapy
• Malaise and fatigue (with extensive • For secondary bacterial infection give
involvement). antistaphylococcal oral antibiotics (e.g.
• Regional lymphadenopathy (with flucloxacillin 500 mg four times per day
secondary bacterial infection). for 7 days).
• Fever (with severe secondary bacterial • A sedating oral antihistamine at bedtime
infection). (e.g. hydroxyzine 25 or 50 mg) will relieve
• Erythroderma (see p. 51). itch and improve sleep.
• A short, reducing course of oral
INVESTIGATIONS corticosteroids can be helpful to induce
• The diagnosis is usually made clinically. remission (e.g. prednisolone
• Skin swab for bacteriology (S. aureus 20–30mg/day and reducing by 5 mg
infection occurs commonly). every 5th day).
• Skin swab for virology (if secondary
infection with HSV is suspected). LONG-TERM MANAGEMENT ISSUES
• Swab of anterior nares for bacteriology Adherence to appropriate skin care is essential to
(to exclude nasal carriage of S. aureus). maintain a remission: regular use of an emollient,
• Blood count, basic chemistry, liver bath oil, and soap substitute is essential. Other
function tests (if considering systemic conservative measures should be considered:
immunosuppressant therapy or if the cotton clothing, the control of house dust mite
patient is systemically unwell). in the home, and behaviour modification techni -
ques to prevent scratching. Nasal carriage of S.
IMMEDIATE MANAGEMENT aureusneeds to be treated with fusidic acid or
Topical therapy mupiricin ointment or chlorhexidine cream
• General emollient therapy. applied to theanterior nares three times per day
• Corticosteroid ointment, twice per day for 7 days. Intermittent use of topical corti-
(use for a restricted period): costeroid or immunomodulator (e.g. tacrolimus,
face: mildly potent. pimecrolimus) is usually necessary. Patients with
trunk and limbs: moderately potent. severe, recalcitrant AD need to be under the care
• A gauze bodysuit can be used to maximize of a dermatologist and may require treatment
the effects of topical therapy. with second-line therapy, such as phototherapy
or systemic immunos uppressants (e.g. azathio -
prine or ciclosporin).
4Atopic dermatitis. 4 5
Repeated scratching
aggravates
inflammation,
produces
excoriations, and
increases the
likelihood of
secondary infection.
5Impetiginized atopic dermatitis. Golden or
honey-coloured crusts overlying eczema
indicate secondary infection with S. aureus.
