comorbidities, oral antibiotics (fl ucloxacillin 1g/6h PO; if MRSA suspected or proven doxy cycline 200mg STAT then 100mg/24h PO) If signs of systemic upset (itemp, iHR, iRR) or coexisting disease (DM, IHD, PVD) admit for short-course IV antibiotics (fl ucloxacillin 1g/6h IV; if MRSA suspected or proven vancomy cin 1g/12h IV) \200 If profoundly unwell, request senior help immediately and consider 3necrotising fasciitis (b p413) Painful or restricted eye movement, proptosis or visual disturbance all suggest 3orbital cellulitis, an ophthalmology emergency. Erythematous cannula sites Cannulae should be resited every 72h to prevent local infection. If a cannula site is red and infl amed or pus is present, take a skin swab for C+S, remove cannula, and clean and dress the site. Give fl ucloxacillin 1g/6h PO or clarithromycin 500 mg/12h PO (if penicillin allergic) for 5d. OHFP.indb 412 OHFP.indb 412 30/05/2014 16:18 30/05/2014 16:18 413 BACTERIAL INFECTIONS CAUSING A RASH 3Necrotising fasciitis (OHAM3 b p473) Symptoms rapidly spreading painful erythema with feat ures of systemic sepsis, fever, sweating, N+V, diarrhea, anorexia, dGCS; may occur at break in skin or operation site but often no apparent skin trauma. Signs rapidly spreading blanc hing erythema (outline area with marker to observe rate of spreading), blisters, oedema, lymphadenopathy in draining nodes, sometimes crepitus over tissues, itemp, iHR, iRR, dBP. I nvestigations blds iWCC and N \230, iCRP/ESR; blood cultures and skin swabs/tissue aspirati on may identify infective organism(s) but do not withhold treatment to do these tests if pa tient is systemically unwell; X-ray may reveal gas in subcutaneous tissues of aff ected are a. Treatment \200\223 3this is a surgical emergency. \200 Seek senior help immediately ( the moment you suspect, not once you have watched the fasciitis evolve and confi rm your su spicions) Surgical debridement is the most important measure, consult senior surgeon without delay Likely to need a combination of IV benzylpenicillin, gentamicin, clindamycin, and metronidazole \200\223 seek urgent microbiology advice. Pathogens may be a mixture of aerobic and anaerobic organisms seen following abdominal surgery or in diabeti cs (type 1), a group A strepto- coccus (type 2) or clostridia (type 3 \200\223 gas gangren e). Outcome depends upon speed of identifi cation and initiation of treat- ment, as well as comorbidity and the site aff ected. Extensive tissue loss from surgery and necrosis is com mon; overall mortality is 725%. 3Meningococcal septicaemia (OHCM9 b p832) Symptoms include fever, joint and muscle ache, non-blanching (purpuric) rash, N+V, diarrhea, anorexia, malai se; meningitis frequently occurs, refl ected by headache, neck stiff ness and photophobia. Signs itemp, iHR, iRR, cap refi ll >2s, dBP, non-blanching petechial or purpuric rash; meni ngism/photophobia if meningitis also present (b p360). Investigations blds iWCC and N \230, iCRP/ESR, meningococcal PCR, deranged clotting if severe sepsis (DIC); blood cultures do n ot withhold antibiotics before taking these if patient is systemically unwell. Treatment \200\223 3this is a medical emergency \200 Airway, Breathing (give O2), Circulation (obta in IV access) \200 Seek help immediately \200\223 contact your seniors as soon as you su spect \200 If patient is in shock (systolic BP <100), involve ICU team urgently \200 0. 9% saline 1l STAT IV and goal-directed fl uid resuscitation (b p481) \200 Ceftriaxone 4g STAT IV if septicaemia is suspected \200 Inform public health consultant once patient is stable. Pathogen Neisseria meningitides, a Gram-negative diplococcus; since the introductio n of a vaccine for serogroup C, serogroup B accounts for the majority of infections seen in Europe and North America. Outcome depends upon speed of identifi cation and initiation of treatment. Mortality for meningococcal septicaemia is about 10% in the developed world. Com plications in survivors include neurological defi cits (eg cogni- tive impairment, deafness ), limb amputation, renal failure and adrenal failure (Waterhouse \200\223Friderichsen synd rome). _OHFP.indb 413 _OHFP.indb 413 30/05/2014 16:18 30/05/2014 16:18 414 CHAPTER 14 Skin and eyes Viral infections causing a rash Chickenpox (varicella zoster virus \200\223 VZV) (OHCM9 b p400) Symptoms begin with fever and malaise 14 \200\22321d after exposure to VZV. The typic al rash then develops: Flat lesions initially, evolving to itchy scabs. Older children and adults are at risk for the development of pneumonitis or encephalitis, manifesting as breat hlessness or altered mental function. Signs itemp, iHR, and presence of evolving rash; macu les, papules, vesicles, pustules, scabs, in centripetal distribution (spreading out from th e trunk). iRR and dO2 sats suggest respiratory involvement. Altered personality, dGCS, or a taxia suggests CNS involvement. Investigations not usually undertaken but vesicular \202 uid can be exam- ined under electron microscopy or sent for viral PCR; serology viral antib ody titres can be monitored but this is seldom necessary; CXR may show diff use consolidati on in varicella pneumonitis; CT brain to exclude other causes of neurology in presumed vari cella encephalitis. Treatment for simple cutaneous disease is symptomatic with antipyretics and topical antihistamines. Antiviral therapy is usually given to patients >16yr (aciclovi r 800mg/5h PO). In the immunocompromised or those with rare complications (pneumonitis, enc ephalitis) use aciclovir 10mg/kg/8h IV. Consider ICU admission for respiratory support in p neumonitis. Pregnancy Primary VZV infection during the 1st 20wk of pregnancy is associ- ate d with 1 \200\2232% risk of fetal anomalies and spontaneous abortion; infection within 5 da ys of delivery is also associated with a risk of neonatal VZV infec- tion. Women without a clear history of chickenpox should have viral specifi c IgG titres checked and if negative, should be off ered 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 gy disease, and oral aciclovir if the disease develops \200\223 discuss with micr obiology. p Chickenpox very rarely occurs in the same individual twice. Shingles only occurs in patient s who have had chickenpox previously; the virus lies dormant in the dorsal root/cranial ner ve ganglia. Non-immune individuals can catch chickenpox from patients who have either chick enpox or shingles; the infectious period runs from 48h prior to onset of the rash until all lesions crust over. Shingles (herpes zoster) Symptoms initially focal pain, followed by classical blistering ra sh in a dermatomal distribution (will not cross the midline), malaise. Signs observations often normal; erythematous papules, evolving into vesicles with pustules which crust over after 77d. Typical occurs in a thoracic or lumbar dermatome. Investigations not usually und ertaken but vesicular \202 uid can be examined under electron microscopy or sent for vira l PCR. Treatment antiviral therapy limits post-herpetic neuralgia if started within 72h (ac iclovir 800mg/5h PO); parenteral antivirals should be used in immunocompromised (aciclovir 10mg/kg/8h IV). Treat pain with simple analgesia (paracetamol, NSAIDs) and amitriptyline 25 mg/24h PO. \200 Herpes zoster ophthalmicus: Involvement of the ophthalmic branch of the t rigeminal nerve (CN Va); may lead to sight threatening keratitis; apply 3% aciclovir ointme nt to eye/5h and seek ophthalmic opinion \200 Ramsay \200\223Hunt syndrome (OHCM9 b p505) : facial pain, vesicles in external auditory canal and ipsilateral facial palsy; complete r ecovery in <50%. OHFP.indb 414 OHFP.indb 414 30/05/2014 16:18 30/05/2014 16:18 415 VIRAL INFECTIONS CAUSING A RASH Measles (Rubeola) Symptoms prodrome of fever, coryza and cough; rash spreading from face an d neck to trunk and limbs. Signs itemp, iHR, conjunctivitis, pathognomonic gray \200\230Ko plik \200\231 spots on buccal mucosa seen 72d prior to appearance of maculopapular rash. In vestigations none required routinely; respiratory swab PCR in critically ill. Treatment sup portive care; vitamin A supplements if malnourished; comp- lications include pneumonitis, p neumonia, encephalitis; subacute sclerosing panencephalitis is a degenerative CNS disease a ppearing 710yr after infection. Rubella (German measles) Symptoms rash with fever and coryz a; adults may experience arthralgia. Signs discrete macular rash spreading from face to tru nk and limbs; features of concurrent illness/infection (itemp, iHR, etc); tender lymphadeno pathy. Investigations none routine; blds iviral specifi c IgM during infection. Treatment s upportive care; primary infection during 1st trimester of pregnancy carries 790% fetal anom alies (eg deafness, cataracts). Viral exanthema (the viral rash) Symptoms rash associated w ith prodromal symptoms of viral illness (fever, myalgia, arthralgia, headache); may or may not be itchy. Signs widespread maculopapular rash; features of concurrent illness/ infectio n (itemp, iHR, pharyngitis, etc). Rash associated with numerous viruses (echovirus, parvovi rus, EBV, measles) so not diagnostic. Investigations none required routinely; discuss with virology if unwell. Treatment simple analgesia and topical antihistamines; resolves over 77 d. Fifth disease ( \200\230slapped cheek \200\231 fever) Symptoms non-itchy rash on cheeks, which feel burning hot; later spreads to trunk and limbs; headache; otherwise well; usuall y in children. Signs dense erythematous rash on cheeks, and reticulate erythema (net-like r ash) on proximal limbs; caused by parvovirus B19. Investigations none required routinely. T reatment rash will subside over 7 \200\22310d; treat concurrent symptoms. Herpes simplex vi rus (cold sore/genital herpes) Symptoms small painful blisters usually around mouth or in g enital area. Signs vesicles or pustules around mouth (usually HSV1) or in genital area (usu ally HSV2). Often resolve, but then return months or years later. Investigations not usuall y undertaken but vesicular \202 uid can be examined under electron microscopy or sent for viral PCR. Treatment consists of aciclovir 200mg/5h PO for primary HSV infections and pain ful genital infections. Treat facial and genital \200\230cold sores \200\231 with aciclovi r 5% to aff ected area/4h topically. Molluscum contagiosum (water blisters) Symptoms small, non-itchy spots, occurring on trunk and limbs in childhood (skin contact) and around groin in early adulthood (sexual transmission); highly contagious. Signs small translucent vesic les (1 \200\2233mm), which look fl uid-fi lled, but are actually solid, often with the cent ral depression (punctum). Caused by a poxvirus, and usually resolve spontaneously after 6 \200\22312mth. Investigations none routine; screen for other STDs in adults (b p465). Treat ment cryotherapy can be used in older children and adults. _OHFP.indb 415 _OHFP.indb 415 30/05/2014 16:18 30/05/2014 16:18 416 CHAPTER 14 Skin and eyes Fungal infections causing a rash Dermatophytes are pathogenic fungi capable of causing a ra nge of diseases. Tinea corporis ( \200\230ringworm \200\231): mildly itchy, asymmetrical ra sh which spreads with a slightly raised, scaly edge, often leaving a clear center. Tinea fa ciei superfi cial, itchy infection of face. Tinea cruris is essentially ringworm in the gro in, though this lesion is often red and more plaque-like with a well demarked border. Tinea pedis also known as \200\230athlete \200\231s foot \200\231, is usually found in the webs paces of the toes, resulting in itchy skin which is fi ssured and macerated. If found elsew here on the foot it is often more diff use and scaly, but just as itchy. Pustules are not u ncommon in more aggressive disease. Treatment of small focal areas of tinea can be achieved with topical antifungal creams (terbinafi ne, clotrimazole, miconazole, etc); more widespr ead infections require oral therapy (terbinafi ne, itraconazole). Candida albicans Candida is a yeast, and thrives in warm moist areas, in children \200\231s nappies (nappy rash), in body folds (intertrigo), and also in interdigital webspaces, mimi cking tinea pedis. The rash is erythematous with a ragged, peeling edge which may contains small pustules. The mouth and genital tract can also be aff ected and present with small wh ite plaques/white discharge. Treatment consists of removing predisposing factors (ensure sk in remains clean and dry) and topical antifungal creams (as for tinea); use drops (eg nysta tin) or pessaries (eg clotrimazole) for oral and genital tract infections respectively; res istant infections may require oral therapy (eg fl uconazole). Infestations causing a rash Scabies is an intensely itchy rash, often worse at night, cause d by the scabies mite, Sarcoptes scabiei. Commoner in children and with social overcrowding . The rash is papular and usually in the interdigital webspaces of the hands and feet, arou nd the ankles, wrists, axillae and umbilicus. Linear skin burrows are pathognomonic but not always present. The diagnosis can be confi rmed by microscopic examination of skin scrapin gs, looking for mites or their eggs. Highly contagious. Treatment with a scabicide (malathi on or permethrin) is only successful if the whole body is treated, if all close contacts ar e treated and if bedding and clothing are washed. Itching may last up to 4wk after treatmen t. Lice are blood-sucking parasites. Head lice (Pediculosis capitis) are commonest in child ren, spread by direct contact and can result in scalp excoriation. The presence of eggs ( \200\230nits \200\231) in the hair confi rms the diag- nosis. Body lice (Pediculosis corpor is) are associated with poverty and not often seen in the developed world; excoriations on the skin are often the only sign. Pubic lice (Phthiriasis pubis or \200\230crabs \200\231) are transmitted by sexual contact and largely aff ect the coarse hairs of the pubic region , but can infest leg and body hair, as well as eyelashes and eyebrows. Treatment is with ma lathion or permethrin, but resistance is common and close contacts should also be treated; clothing and bedding should be thoroughly washed. OHFP.indb 416 OHFP.indb 416 30/05/2014 16:18 30/05/2014 16:18 417 CHRONIC INFLAMMATORY RASHES Chronic in \202 ammatory rashes (OHCS8 b p596) Dermatitis (eczema)1 found in 710% of the p opulation in various forms: \200 Atopic onset usually in childhood; associated with asthm a and allergies \200 Contact infl ammatory response to skin irritant; may blister \200 Venous stasis seen in lower limbs of older patients; hyperpigmented \200 Seborrhoeic itch y scaling of scalp associated with reaction to skin fungi. Symptoms include itchy, dry skin , or patches of infected skin. Signs erythematous patches with excoriations from itching; i n atopic eczema these typically aff ect the fl exures of the elbow, knees and around the ne ck; vesicles and serous weeping may be a feature. Superimposed bacterial or viral infection s are common. Aff ected skin may develop chronic lichenifi cation and hyperpigmentation. Tr eatment is multifactorial and depends on underlying cause. Attempt identifi - cation and av oidance of known irritants. In atopic eczema, triple therapy with topical steroids (b p178) , topical emollients and bath oil and soap substi- tutes form the mainstay; step 4 treatmen ts such as UVB/PUVA, ciclosporin and azathioprine may be prescribed by a dermatologist (Fig . 14.1). Treat bac- terial superinfection promptly eg fl ucloxacillin 500mg/6h PO. Step 4 l Recalcitrant, severe eczema a c p o t Systemic therapy (eg ciclosporin) or UV therapy t n e m t a e r t i t n e m t a e r t e u n i t n o Step 3 e s a e s i d Moderate to severe eczema Mid-high potency topical corticosteroids c i s a b e u n i t n o C and/or topical calcineurin inhibitors \200 C Step 2 f o y t i s n e t n Mild to moderate eczema Low-mid potency topical corticosteroids Step 1 I Basic treatment skin hydration, emollients, avoidance of irritants, identification and addr essing of specific trigger factors Dry skin only Fig. 14.1 Step-wise management of atopic eczema. \200 Calcineurin inhibitors include pime crolimus (Elidel ) and tacrolimus (Protopic ). Reproduced from Akdis, C.A. et al. Diagnos is and treatment of atopic dermatitis in children and adults J Allergy Clin Immunol 2006 11 8:152 \200\22369. (2006), with permission from Elsevier. Available free at (cid:27)www.j acionline.org Psoriasis2 infl ammation of the dermis, with epidermal hyperprolifera- tion. Occurs in 72% of the population, with peak incidences in the early 20s then again in the 50 s. Exacerbations can be precipitated by infec- tions, drugs (eg lithium, B-blockers), UV li ght, alcohol and stress. Symptoms itchy, dry patches of skin which can bleed when scratched . Signs of chronic plaque psoriasis are pink/red scaly plaques, especially on the extensor surfaces of elbows and knees, lower back and scalp; nail pitting is common; pustular psoria sis aff ects palms and soles; guttate psoriasis occurs suddenly, often 2 \200\2233wk after a streptococcal throat infection, causing numerous small pink papules on the trunk; \202 exural psoriasis tends to occur in later life, and forms in the groins, natal cleft and sub mammary area Treatment is symptom-led and largely topical; emollients, mild to mod- erate t opical steroids, vitamin D analogs, retinoids and purifi ed coal tar are common topical tre atments. Use of UVB/PUVA, anti-TNF therapy, methotrexate and ciclosporin may be considered by a dermatologist. 1 NICE childhood eczema guidelines available at (cid:27)guidance.nice.org.uk/CG57 2 NICE ps oriasis guidelines available at (cid:27)guidance.nice.org.uk/CG153 _OHFP.indb 417 _OHFP.indb 417 30/05/2014 16:18 30/05/2014 16:18 418 CHAPTER 14 Skin and eyes Other causes of rash Urticaria also known as \200\230hives \200\231 or \200\230nettle ras h \200\231 is characterized by the for- mation of intensely pruritic papules or plaques ( \200\230weal \200\231) which are pale initially but become erythematous with a surrounding rim of pale skin or erythema ( \200\230fl are \200\231). Common in response to certain topi cal chemicals (eg nettle sting) but also in response to systemic drugs (sometimes part of a naphylaxis) or antigens (during a blood transfusion). Can also occur as part of the rare he reditary angioedema syndrome, due to defi ciency in plasma C1 esterase inhibitor (OHCS8 b p 603). Erythema nodosum is characterized by tender, erythematous nodules, typically on the s hins. Commoner associations include: infections (tuber- culosis, streptococcal, Mycoplasma pneumoniae and EBV), sarcoidosis, infl ammatory bowel disease, autoimmune disorders, pregna ncy and drugs (sulfonamides and the oral contraceptive pill) (OHCS8 b p588). Erythema multi forme is a hypersensitivity rash and has two subtypes. Erythema multiforme minor produces \200\230target \200\231 lesions, with a red center, a clear circular area, and an outer red ring. Erythema multiforme major is a similar rash with involvement of one or more mucous m embranes (classically the mouth). Often no precipitant is identifi ed (750%) but associatio ns are rec- ognised with several infections (eg HSV, adenovirus, Mycoplasma pneumonia) and drugs (eg sulfonamides, NSAIDs, penicillins) (OHCS8 b p588). Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) represent diff erent extents of severe, life-threat- ening skin infl ammation (considered by some to be an extreme form of erythema multiforme) that is usually drug induced. Widespread blisters, with sloughing, erythematous macules and mucosal erosions aff ect <10% body surface area (SJS) or >30% (TEN) with an overlap diagno sis in between. There is a signifi cant mortality and senior help should be sought immediat ely, with close attention to skin care, fl uid replacement and prevention of superinfection (OHCS8 b p609). Pemphigus and pemphigoid are rare primary blistering diseases. Pemphigus c auses superfi cial blisters and often involves the mucous mem- branes of the mouth; the bli sters are delicate and burst easily, so areas of raw skin are often more noticeable than bl isters. Pemphigoid causes tense blisters in older patients, and seldom aff ects the mouth. Both forms are autoimmune and require dermatology assessment (OHCS8 b p602). Pyoderma gangr enosum presents with nodules or pustules which often ulcerate, leaving a blackened ulcer wi th a purulent surface. Associated with infl ammatory bowel disease, primary biliary cirrhos is, and rheumatoid arthritis amongst others, the exact cause remains unclear. Needs urgent dermatology assessment (OHCS8 b p588). Henoch \200\223Sch nlein purpura is self-limiting s mall vessel vasculitis typi- cally seen following a simple upper respiratory tract infectio n in childhood. Petechiae and purpura develop on the legs and buttocks and may be associ- a ted with abdominal pain, arthralgia and oedema (OHCS8 b p197). Granuloma annulare is a comm on, benign infl ammatory disorder of unclear etiology, characterized by clusters of papules appearing on the hands, feet or trunk which later merge into a ring. Associations include T1DM, but most cases appear in otherwise healthy individuals (OHCS8 b p586). 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