There are only a few true dermatological emergencies, but skin problems are a common cause of ER visits. Red, scaly, itchy, painful, blistered are all part of the skin game.
Toxic epidermal necrolysis is a life threatening skin problem. It is seen in Steven-Johnson syndrome, a hypersenitivity reaction that may be caused by many commonly used medications. The skin and mucous membranes are effected and the treatment is similar to that for severe burns. Scalded skin syndrome, caused by certain staphylococcal infections is characterized by fluid filled blisters as the outer layer of skin separates from the deeper layers. This separation with only slight pressure is referred to as Nikolsky's sign. This condition is also treated in a burn center.Pemphigous is an autoimmune disease that also presents with painful blisters. It may be associated with certain cancers.
Skin infections are often seen in the ER. Fungal infections of the skin are caused by dermatophytes. Ringworm, athlete's foot, and jock itch are all common names for fungal skin infections. Tinea versicolor presents with patches of of skin that are a different color than the normal surrounding skin. Tinea pedis, pubis and capitis refer to fungal infection from the bottom, middle and top of the body. While not life-threatening, the ER docs and PA's can initiate treatment for these conditions.
Viral skin infections are potentially more serious. Herpes infections caused by herpes simplex either types 1 or 2 are painful eruptions of small blisters (vesicles) around the mouth or genitals. Occasionally a herpetic whitlow presents as painful vessicles on a finger tip from the patient contaminating his or hers finger from touching/scratching vesicles around the mouth or genitals. Shingles is caused by the herpes zoster virus. This virus is also the cause of varicella (chicken pox). Many species of herpes virus have the ability to "hide" in ones body and recur years after the initial infection. Shingles describes a recurrence along the distribution area of a nerve. It is almost always unilateral and looks like a patch or swath of vesicles on a red base. The incidence of shingles increases as we age. It is a very painful condition and the pain often persists even after the rash clears. Fortunately there a booster vaccination for patients older than 60 that has been shown to decrease the incidence of shingles and to both shorten the course and the postherpetic neuralgia (nerve pain) if shingles does occur.
Many diseases have distinctive rashes as part of the illness. Measles, chicken pox, rubella, Rocky Mountain spotted fever, Lyme disease and many other viral and bacterial infections will have rashes as part of the signs of the illness.
Bacterial skin infections are common and need urgent treatment. Erysipelas is a painful skin eruption caused by strep. pyogenes. Impetigo is a common childhood skin infection caused when scratching by the patient, breaks the surface of the skin and strep or staph bacteria are inoculated into the skin. Impetigo is often seen in sports where skin to skin contact occurs, such as wrestling. Cellulitis presents as a localized red, warm and tender skin. The margin of the cellulitis is often elevated above the normal skin. Staph and strep bacteria are the most common organisms. Impaired immunity because of medications or diabetes increases the incidence and severity of cellulitis.
By far the most common dermatological conditions seen in the ER are those caused by inflammation. Contact dermatitis by irritants such as solvents, alkalies, latex and plants presents with area of small vesicles, sometimes "weeping". Allergic dermatitis looks similar and is most often seen with exposure to poison ivy, oak, sumac and metals such as nickel. That gold or silver jewelry you are wearing may contain nickel as a hardener. Photodermatitis occurs when an irritant or allergen is on the skin or has been ingested (many medications) and the ultraviolet light from sun exposure triggers a reaction.
Eczema is a chronic form of dermatitis that may present with some combination of redness, itching, dryness, crusting, flaking, blistering, cracking, oozing or bleeding. Eczema like contact dermatitis is treated with topically applied or orally administered corticosteroids.
Psoriasis is a chronic immune mediated skin disease. Thick flaky patches may occur anywhere on the body. Topical steroids may help with an acute flair up. PUVA (psoralens and ultraviolet A phototherapy) and immune modulators such as methotrexate or cyclosporin are used to treat this chronic condition.
Patients with sunburns are frequently seen in the ER at this time of the year. Moisturizers, pain medications and occasionally corticosteroids are prescribed. Prevention by limiting ones exposure, and using sunblock are the preferred method of not getting burned. Apply copious amounts of at least SPF 30 sun block, twenty minutes before sun exposure. Reapply every 2 hours or more frequently if swimming or sweating. As I found out on while snorkeling on the island of Anguilla, remember to protect ones bald spot.
World's oldest ER doc update: I have begun the next phase of my ER career. I am now working at a low volume/ low acuity community hospital. Although this move was forced on me by the adminstration of my former hospital, the slower pace and reduced stress will allow me to reach my goal of 40 years as an ER doc.
