How many Rashes - snapaprn.org

How many Rashes - snapaprn.org

Y M H O , S E H S A R , C -B

P N F , N R , P N D AD, T S R A

-H Y S S E N N E H DR. ELLEN CPN CONFLICT OF INTEREST DR. HENNESSY-HARSTAD CONFIRMS THAT SHE HAS NO CONFLICT OF INTEREST IN THIS PRESENTATION.

OBJECTIVES PARTICIPANTS WILL IDENTIFY SEVEN SERIOUS RASHES AND TREATMENT PARTICIPANTS WILL UTILIZE AN DIAGNOSTIC DECISION TREE TO IDENTIFY RASHES AND HOW TO TREAT PARTICIPANTS WILL IDENTIFY MEDICATIONS MOST FREQUENTLY USED FOR TREATMENT OF RASHES PARTICIPANTS WILL RECOGNIZE WHEN TO REFER PATIENTS TO SPECIALISTS BY THE NUMBERS SKIN CONDITIONS AFFECT 20-30% OF THE POPULATION COST EXCEEDS $96 BILLION DOLLARS A YEAR 1 IN 3 PERSONS IN US ARE AFFECTED AT ANY GIVEN TIME

MISDIAGNOSIS OF RASHES CAN RESULT IN UNNECESSARY OFFICE VISITS UNNECESSARY OR WRONG PRESCRIPTIONS INCREASED COSTS PATIENT SUFFERING, DISFIGUREMENT AND EVEN FATALITY TIME CONSTRAINTS ARE REPORTED AS A LEADING REASON FOR MISDIAGNOSIS. AWAWLLDA ET AL. (2008). WHY SO HARD TO DIAGNOSE? NEARLY 2,200 DISEASES AND DISORDERS AFFECTING THE SKIN

DIFFERENT CONDITIONS BUT SIMILAR RASHES (I.E., BOTH PSORIASIS AND FUNGAL RASHES CAN APPEAR SCALED6-9) SINGLE SKIN CONDITION CAN RESULT IN DIFFERENT PRESENTATIONS. FOR EXAMPLE, CONTACT DERMATITIS MAY PRESENT WITH A VESICULAR, SCALED, PAPULAR OR MACULAR RASH.10,11 DERM EMERGENCIES HTTP:// WWW.MIDLEVELU.COM/BLOG/DERMATOLOGIC-EMERGENCIES-7-RASHES-NPS-MUST-BE-A BLE-IDENTIFY ANGIOEDEMA MENINGOCOCCEMIA ROCKY MOUNTAIN SPOTTED FEVER

NECROTIZING FASCIITIS STEVENS JOHNSON SYNDROME (SJS) AND TOXIC EPIDERMAL NECROLYSIS (TEN) TOXIC SHOCK SYNDROME ERYTHRODERMA (GENERALIZED EXFOLIATIVE DERMATITIS) ANGIOEDEMA SUBSTANTIAL LOCALIZED FACIAL SWELLING, ANGIOEDEMA CAN HAVE SYSTEMIC EFFECTS. ASSOCIATED WITH ANAPHYLACTIC REACTION SHORTNESS OF BREATH, CHANGES IN VOICE, TONGUE SWELLING OR THROAT TIGHTNESS AS THESE SYMPTOMS INDICATE AIRWAY INVOLVEMENT. 50% OF PATIENTS WILL HAVE URTICARIA. HISTORY OF ACE INHIBITOAN

ALLERGEN OR THE DISEASE MAY BE HEREDITARY. TREATMENT INVOLVES REMOVING THE OFFENDING MEDICATION OR ALLERGEN FROM THE PATIENT'S ENVIRONMENT, ANTIHISTAMINES AND STEROIDS. EPINEPHRINE AND SUPPORTIVE AIRWAY TREATMENT MAY BE NECESSARY IF THE AIRWAY IS INVOLVED. MENINGOCOCCEMIA PETECHIAL RASH INITIAL PRESSENTATION: FEVER AND RASH FOLLOWED BY FATIGUE, FEVER, HEADACHE AND BODY ACHES. THE RASH: PETECHIAE, SMALL RED SPOTS THAT DO NOT BLANCHE WITH PRESSURE

RASH APPEARS ANYWHERE ON THE BODY INCLUDING THE PALMS AND SOLES OF THE FEET. MENINGOCOCCEMIA CAN LEAD TO MENINGOCOCCAL MENINGITIS, DIC, SHOCK AND DEATH TREATMENT: AGGRESSIVE ANTIBIOTIC INTERVENTION FEBRILE PATIENTS PRESENTING WITH PETECHIAL RASH SHOULD BE SUSPECTED OF HAVING A MENGOCOCCEMIA DIAGNOSIS. BLOOD CULTURES MUST BE DRAWN AND THE PATIENT TREATED WITH IV ANTIBIOTICS UNTIL MENINGOCOCCEMIA IS RULED OUT WITH CULTURE RESULTS. ROCKY MOUNTAIN SPOTTED FEVER CARRIED BY TICKS,

TYPICAL PRESENTATION: TRIAD OF FEVER, HEADACHE AND RASH. PATIENTS WHO ARE ADEQUATELY TREATED HAVE A MORTALITY RATE OF JUST 3 TO 7% UNTREATED PATIENTS AND PATIENTS IN WHOM THE DISEASE IS NOT TREATED PROMPTLY HAVE A MORTALITY RATE OF 30 TO 70%. THE RASH : TYPICALLY APPEARS FIRST ON THE ANKLES AND WRISTS THEN SPREADS TO THE PALMS, SOLES AND EVENTUALLY THE TRUNK AND FACE.

BEGINS AS A MACULAR RASH MANIFESTING AS FLAT, PINK SPOTS PROGRESSING TO A RED, MORE PROMINENT PETECHIAL RASH. COMPLICATIONS OF RSR INCLUDE ACUTE RENAL FAILURE, HEPATIC FAILURE, CARDIOGENIC SHOCK, DIC AND MENINGITIS TREATMENT: ANTIBIOTICS, NECROTIZING FASCIITIS NECROTIZING FASCITIS IS CHARACTERIZED BY NECROSIS OF THE SUBCUTANEOUS TISSUE AND FASCIA BY GROUP A STREPTOCOCCUS TYPICAL PRESENTATION: INITIAL SWELLING AT THE SITE FOLLOWED BY INTENSE PAIN AND

TENDERNESS. PAIN, TYPICALLY OUT OF PROPORTION TO THE EXTERNAL RASH, IS PRESENT SYSTEMIC SYMPTOMS: FEVER, MALAISE, MYALGIA LARGE BULLAE OFTEN DEVELOP IS ASSOCIATION WITH THE RASH. RISK FACTORS: DIABETES, IMMUNOSUPPRESSION ION AND PERIPHERAL VASCULAR DISEASE. NECROTIZING FASCITIS CAN LEAD TO GANGRENE, SHOCK AND ORGAN FAILURE. MORTALITY IN NECROTIZING FASCITIS RANGES FROM 20 TO 80%. EARLY IDENTIFICATION, AGGRESSIVE TREATMENT WITH ANTIBIOTICS

AND SURGICAL DEBRIEDMENT OF THE AFFECTED AREA ARE NECESSARY TO IMPROVE SURVIVAL OUTCOME. STEVENS JOHNSON SYNDROME (SJS) AND TOXIC EPIDERMAL NECROLYSIS (TEN) SEVERE DRUG-INDUCED HYPERSENSITIVITY RASH: MACULES THAT QUICKLY SPREAD AND COALESCE FORMING BLISTERING, NECROTIC, SLOUGHING LESIONS AND DESQUAMATION. TWO OR MORE MUCUS MEMBRANES ARE TYPICALLY INVOLVED INCLUDING THE ORAL OR BUCCAL MUCOSA AND THE GENITALIA. SULFA DRUGS, ANTI-EPILEPTICS AND OTHER ANTIBIOTICS ARE THE MOST COMMON DRUGS CAUSING THESE RASHES

OCCASIONALLY, SJS AND TEN ARE IDIOPATHIC. THEORY: RESULT OF THE INABILITY OF THE BODY TO DETOXIFY DRUG METABOLITES. RASH TYPICALLY BEGINS TO APPEAR 1 TO 3 WEEKS AFTER TAKING THE DRUG. MORTALITY RATE OF 20 TO 25%. LOSS OF EPITHELIAL TISSUE LEADS TO SECONDARY INFECTION, FLUID LOSS AND ELECTROLYTE IMBALANCE. TREATMENT IS SIMILAR TO THAT OF BURNS AND IS LARGELY

SUPPORTIVE. TOXIC SHOCK SYNDROME LIFE-THREATENING CONDITION CAUSED BY GROUP A STREPTOCOCCUS OR STAPHYLOCOCCUS AUREUS. 50% OF CASES RESULT FROM SUPERABSORBANT TAMPON USE, OTHER CAUSES INCLUDE SURGICAL INFECTION, POSTPARTUM INFECTION, BURNS AND OSTEOMYELITIS. PRESENTATION: 2-3 DAY PRODROME OF MALAISE FOLLOWED BY FEVER, CHILLS, NAUSEA, RASH AND ABDOMINAL PAIN.

THE RASH APPEARS FIRST AS ERYTHEMATOUS MACULES OR PETECHIAE FOLLOWED BY DESQUAMATION. LOOKS LIKE A SUNBURN. BEGINS ON THE TRUNK AND SPREADS PERIPHERALLY TO THE EXTREMITIES, PALMS AND SOLES. PATIENTS BECOME HYPOTENSIVE AND SUFFER FROM MULTI-ORGAN FAILURE, USUALLY IN 3 OR MORE BODY SYSTEMS. TREATMENT INCLUDING SUPPORTIVE THERAPY AS WELL AS ANTIBIOTIC THERAPY MUST BE INITIATED IMMEDIATELY AS TOXIC SHOCK SYNDROME HAS A MORTALITY RATE OF 30 TO 70%. ERYTHRODERMA (GENERALIZED EXFOLIATIVE DERMATITIS)

ERYTHEMATOUS, SCALING RASH COVERING AT LEAST 90% OF THE BODY'S SURFACE. MOST CASES OF ERYTHRODERMA ARE IDIOPATHIC. OTHER CAUSES INCLUDE PSORIASIS, ECZEMA, DRUG REACTION, LEUKEMIA AND LYMPHOMA. PRESENTATION: DIFFUSE PRURITUS FOLLOWED BY MALAISE, FEVER, CHILLS AND RASH. SCALING OF THE SKIN APPEARS 2 TO 3 DAYS AFTER ONSET OF THE RASH. CAUSE: EXCESSIVE VASODILATION AND THEREFORE

HYPOTENSION, ELECTROLYTE IMBALANCE AND CONGESTIVE HEART FAILURE RESULT. MANAGEMENT IS LARGELY BASED ON SUPPORTIVE THERAPY INCLUDING HYDRATION, ELECTROLYTE MONITORING AND CARDIAC SUPPORT. 43% MORTALITY RATE. CATEGORIZATION OF RASHES INFLAMMATORY: ALLERGIC OR CONTACT DERMATITIS, ATOPIC DERMATITIS, ECZEMA, ERYTHEMA MULTIFORME, GRANULOMA ANNULARE, LICHEN PLANUS, ROSACEA,

SEBORRHEIC DERMATITIS, STASIS DERMATITIS AND URTICARIA. VIRAL: HERPES, MOLLUSCUM CONTAGIOSUM, VIRAL EXANTHEMS AND WARTS BACTERIAL: ACNE, CELLULITIS, FOLLICULITIS, HIDRADENITIS SUPPURATIVA AND IMPETIGO FUNGAL: CANDIDIASIS AND TINEA AUTOIMMUNE: LUPUS AND PSORIASIS MISCELLANEOUS: ACNE NECROTICA, KERATOSIS PILARIS, MELASMA, PRURIGO NODULARIS AND SCABIES. VIRAL RASHES MACULAR PAPULAR RASH MACULARFLAT AND CAN BE RED

PAPULARRAISED AND CAN BE RED CONFLUENTRUN TOGETHER DISCRETEINDIVIDUAL LESIONS MEASLES VESICULAR LESIONS RAISED MAY HAVE A RED BASE FLUID FILLED CHICKEN POX BLISTERS SUCH AS IN SUNBURN BULLAE IF GREATER THAN 1 CM DRUG REACTIONS STEVEN-JOHNSON

BURNS VARICELLACHICKEN POX RASH WITH SCALES ECZEMA DERMATITIS PSORIASIS TINEA Lyons, F. (2012). CASE STUDY A 57-YEAR-OLD WHITE MAN PRESENTS TO A PRIMARY CARE CLINIC WITH A RASH THAT STARTED AS RED, ITCHY PATCHES 2 WEEKS AGO AND THEN PROGRESSED TO BLISTERS.

HE IS EXPERIENCING DISCOMFORT FROM THE ITCHING, BUT SAYS HE IS EXPERIENCING NO PAIN. HE HAS TRIED MULTIPLE OVER-THE-COUNTER PREPARATIONS BUT ACHIEVED NO RELIEF. MR.H. HAS ERYTHEMATOUS AND VESICULAR PAPULES AND PATCHES ON BOTH FOREARMS AND THE TOPS OF BOTH HANDS. HE REPORTS NO HISTORY OF RASHES OR REACTION TO MEDICATIONS EXCEPT AN ALLERGY TO PENICILLIN, WHICH CAUSES HIVES. Using the differential diagnostic decision tree, the clinician notes

that the rash is on both the arms and hands and is vesicular. The next step is to check tier 4 under "hands" and tier 4 under "arms" for vesicular rashes. The differential diagnoses in tier 5 for common vesicular rashes on the arms include contact dermatitis chickenpox, while the diagnoses for the hands include contact dermatitis,

Lichen planus dyshidrotic eczema. Since the vesicular rash is not on the torso or legs, chickenpox most likely is not the cause of this rash. Although lichen planus and dyshidrotic eczema are listed as occurring on the hands, they do not affect the arms and should be eliminated as possible diagnoses. Contact dermatitis is the logical diagnosis. Contact dermatitis is an eczematous dermatitis caused by exposure to substances in the environment.

The substances act as irritants or allergens and may cause acute or subacute or chronic eczematous inflammation. Clinical presentation includes erythematous patches that may include papules, vesicles or scales (if chronic). The intensity of inflammation depends on the degree of sensitivity and the concentration of the antigen. Primary care providers can use information

obtained from the history and physical to validate the selected diagnosis. In this case, further questioning revealed that Mr. H. had begun handling lubricated automotive parts at work shortly before he developed the rash. This fact reinforces the diagnosis of contact dermatitis. WHAT IS THE TREATMENT? REMOVE THE OFFENDING AGENT TOPICAL STEROID CREAM OR OINTMENT ANTIHISTAMINE, SUCH AS BENEDRYL OR ATARAX

FREQUENTLY USED MEDICATIONS TOPICAL STEROIDS ANTIFUNGALS ANTIHISTAMINES ANTIBIOTICS EMOLLIENTS AND CALMING STEROIDS REMEMBER LIGHTTHIN LAYER LOWPOTENCY SHORTDURATION IF USED ON A FUNGAL INFECTION

THE INFECTION WILL GROW ROUTES TOPICAL PO IV ANTIFUNGALS REMEMBER NEED A RING AROUND THE INFECTION POFOR ONE MONTH

IDENTIFY TYPE OF FUNGUS NEED FOLLOW-UP ROUTES TOPICAL CREAMS, SHAMPOOS, FOAMS, GELS PONEEDED FOR TINEA CAPITAS IVSYSTEMIC INFECTION SUPPOSITORIES DIRECT MICROSCOPY POTASSIUM HYDROXIDE (KOH)

PREPARATION, STAINED WITH BLUE OR BLACK INK UNSTAINED WET-MOUNT STAINED DRIED SMEAR HISTOPATHOLOGY OF BIOPSY WITH SPECIAL STAINS, E.G., PERIODIC ACID-SCHIFF (PAS). SPECIMEN COLLECTION-FUNGAL SPECIMENS FOR FUNGAL MICROSCOPY AND CULTURE MAY BE: SCRAPINGS OF SCALE, BEST TAKEN FROM THE LEADING EDGE OF THE RASH AFTER THE SKIN HAS BEEN CLEANED WITH ALCOHOL. SKIN STRIPPED OFF WITH ADHESIVE TAPE, WHICH IS THEN STUCK ON A GLASS SLIDE.

HAIR WHICH HAS BEEN PULLED OUT FROM THE ROOTS. BRUSHINGS FROM AN AREA OF SCALY SCALP. NAIL CLIPPINGS, OR SKIN SCRAPED FROM UNDER A NAIL. SKIN BIOPSY. MOIST SWAB FROM A MUCOSAL SURFACE (INSIDE THE MOUTH OR VAGINA) IN A SPECIAL TRANSPORT MEDIUM. A SWAB SHOULD BE TAKEN FROM PUSTULES IN CASE OF SECONDARY BACTERIAL INFECTION. THEY ARE TRANSPORTED IN A STERILE CONTAINER OR A BLACK PAPER ENVELOPE. Antifungal Agent Activity Usual dosage

Adverse Reactions Drug interactions Patient Education Clotrimazole Candida spp. Oral: Dissolve 1 lozenge 5 X/day for

7-14 days Topicaldaily Intravaginal-100 to 200mg dly for 3-7 days GI (oral); Skin irritation; elevated liver enzymes Tacrolimus Do not use with tampons and

douches. Do not use with occlusive dressings. Ketoconazole Candida spp. Blastomyces, Coccidioides, Histoplasma Matassezia, Prototheca spp. Oral: 200-400 mg/day

Topical 1-2X daily for 2-4 weeks GI upset; Site irritation; hepatotoxicity Alprazolam; cisapride, terfenadine, triazolam, Antacids, anticholinergics, and H2 blockers

should be taken 2 hours after oral administration, Do not wash topical application sites for at least 3 hours after application. Fluconazole Candida supp. Cryptocuccus, Aspergillus spp. Blastomycaes dermatitidis,

Histoplasma, Prototheca spp. Candidiasis: oral 50-150 mg/day Invasive candidiasis: oral 6mg/kg/day (400-800 mg/day) GI disturbances, headache, elevated liver enzymes.

Cisapride, rifabutin , triazolam, warfarin Drug interactions are common, Take tablet with full glass of water. Store suspension at room temperature or refrigerator.

(Owens, Skelley, & Kyle, AZOLE ANTIFUNGALS GROUPS AND INDICATIONS TRIAZOLES AND THE IMIDAZOLES. TREAT SYSTEMIC INFECTIONS TREAT TOPICAL INFECTIONS . ATHLETES FOOT, RINGWORM, ETC WHAT THEY DO

REMEMBER AZOLES DO NOT GET ALONG WELL WITH OTHER DRUGS (727 DRUGS204 W MAJOR INTERACTIONS) HTTP://WWW.DRUGS.COM/DRUG-INTERACTIONS/KETOCONAZOLE-INDEX.HTML? FILTER=3&GENERIC_ONLY= SIDE-EFFECTS ITCHING, STINGING, BURNING, OR IRRITATION SWELLING OF FACE, SORES IN MOUTH, EYE REDNESS DISCOLORATION OF SKIN, BLISTERSYELLOW CRUSTS; DRY OR CRACKED SKIN, PAIN OR REDNESS OF SKIN

DIZZINESS BURNING, CRAWLING, ITCHNESS, NUMBNESS, PRICKLING/TINGLING FEELINGS WATCH FOR MICRO DOSES (GRISEOFULVIN MICROSIZE ORAL SUSPENSION) SCALP INFECTION ANTIHISTAMINES DIPHENHYDRAMINE TOPICAL AND PO

ATARAX LORATADINE GOALCOMFORT DOSE AT STRONGEST ANTIBIOTICS THINGS TO CONSIDER CULTURE BEFORE STARTING THE PREVALENCE OF MRSA SHOULD START TO SEE IMPROVEMENT WITHIN 72 HOURS ROUTES

TOPICAL PO IV ORAL CHOICES 2 AND 3 GENERATION CEPHLOSPORINS SULFAMETHOXAZOLE AND TRIMETHOPRIM (BACTRIM) CLINDAMYCIN ND RD EMOLLIENTS SOFTEN THE SKIN MANY PRODUCTS ON MARKET

EUCERIN, VANICREAM, VASOLINE, LARD STEROID OINTMENT BID FOR 7DAYS SEALING WATER INTO THE SKIN OTHER MEDIHONEY ANTIBACTERIAL ANTIINFLAMMATORY ELIMITE CREAM

TREATMENT OF SCABIES WHEN TO REFER TO SPECIALIST WHEN YOU DO NOT KNOW AFTER THE SECOND VISIT IF THERE IS NO RELIEF IF THE RASH IS ONE OF THE SEVEN DERM EMERGENCIES IF YOUR PATIENT ASKS FOR ONE REFERENCES AMERICAN ACADEMY OF DERMATOLOGY. HTTPS://WWW.AAD.ORG/PRACTICE-TOOLS/QUALITY-CARE/CLINICAL-GUIDELINES

AWADALLA F, ET AL. (2008). DERMATOLOGIC DISEASE IN FAMILY MEDICINE. FAM MED, 40(7), 507-511. ELY JW, STONE MS. (2010). THE GENERALIZED RASH: PART II. DIAGNOSTIC APPROACH. AM FAM PHYSICIAN, 81(6), 735-739. LYONS, F. (2012). SOLVING SKIN RASHES IN PRIMARY CARE. HTTP:// NURSE-PRACTITIONERS-AND-PHYSICIAN-ASSISTANTS.ADVANCEWEB.COM/FEATURES/ARTICLES/S OLVING-SKIN-RASH-IN-PRIMARY-CARE.ASPX OWENS, J. N., SKELLEY, J. W., & KYLE, J. A. (2010). THE FUNGUS AMONG US: AN ANTIFUNGAL REVIEW. US PHARMACIST, 35 (8), 44-56. SIMON, A., ET AL.(2009). MEDICAL HONEY FOR WOUND CARESTILL THE LATEST RESORT?. EVIDENCE BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE, 6 (2), 165-173.

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