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Category: Dermatology

DIAGNOSIS AND TREATMENT OF ATOPIC DERMATITIS RELIES ON UNDERSTANDING THE SKIN BARRIER

DIAGNOSIS AND TREATMENT OF ATOPIC DERMATITIS RELIES ON UNDERSTANDING THE SKIN BARRIER

A patient presents with a rash. In emergency medicine we often recognize certain rashes at a glance, like urticaria or a viral exanthem. This does not fit any of those. The patient is scratching vigorously. Is this atopic dermatitis, commonly known as eczema?   Eczema might be the most common rash we see in the emergency department but its presentations are diverse so it is not always a “know it at a glance” diagnosis. We can get tricked. The etymology…

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CELLULITIS: DON’T JUST LOOK – FEEL!

CELLULITIS: DON’T JUST LOOK – FEEL!

  Cellulitis, when you think about it, is probably not the most helpful term. Literally, it means “infection of cells.” What cells? The anatomical area is actually the dermis, as well as the subcutaneous tissue.   A patient presenting with “dermitis” has a lesion that is clearly confined to the skin. A patient presenting with significant edema has involvement of subcutaneous tissues. These are the patients where we need to consider the surgical diseases: necrotizing fasciitis, pyomyositis, and abscess.  …

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BLISTERING DISEASES: THICK AND THIN

BLISTERING DISEASES: THICK AND THIN

A young child presents with blistering exfoliation over the face and neck. It started around the mouth. It has the appearance of impetigo, with the honey crusted lesions, but other areas have confluent denuding of the skin. You wonder whether this could be staphylococcal scalded skin syndrome (SSSS) or toxic epidermal necrolysis(TEN). How can these be differentiated at the bedside?   These diseases can be differentiated by the thickness of the skin. The toxin of SSSS cleaves at the stratum…

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ECZEMA/ATOPIC DERMATITIS – EPIDERMAL BREACH EXPLAINS THE FINDINGS

ECZEMA/ATOPIC DERMATITIS – EPIDERMAL BREACH EXPLAINS THE FINDINGS

If atopic dermatitis is an atopic disease, why does it only proceed to asthma and allergic rhinitis in 30 and 35% of cases, respectively?(Williams, NEJM 2005)  And why would an allergic disease tend to present at areas of friction or moisture, the extensor surfaces in babies (the friction is from crawling) and in flexural areas in adults?  Or the somewhat peculiar hands and feet eczema?   Atopic dermatis is now believed to be a disease of the epidermal barrier. Breaches…

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SCABIES – CHECK FOR BURROWS

SCABIES – CHECK FOR BURROWS

A patient presents with pruritus and excoriations.  He has a poor social situation and appears disheveled.  Could this be scabies?   Although some diagnostic algorithms are as simple as finding itching in 2 areas of the body (Mahé Trans R Soc Trop Med Hyg 2005) a closer look may prove rewarding.   Distribution: Infection is spread by direct contact, so regardless of where the infection started, the hands and wrists tend eventually to become infected.(Fathy J Egypt Soc Parasitol 2010)…

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THE BURN EXAM IS A MICROVASCULAR EXAM

THE BURN EXAM IS A MICROVASCULAR EXAM

A patient presents with extensive burns to the left hand.  None of the fingers have circumferential burns, but both volar and dorsal aspects do have larger territories affected, with extensive skin sloughing.  How do we use bedside physical examination to guide prognosis and treatment? The physical examination of burns is essentially a microcirculatory examination for signs of viability.  We are evaluating the viability of the dermis, because this is the organ thath will help mediate wound healing.  It has a…

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PHYSICAL DIAGNOSIS OF PURPURIC LESIONS

PHYSICAL DIAGNOSIS OF PURPURIC LESIONS

You evaluate a patient with a rash, and as you look, you notice small patches of purple lesions that are circular in distribution.  You recognize what appears to be purpura.  The differential diagnosis is long, and includes hematologic, infectious, and immune mediated conditions.  How can we use physical diagnosis to narrow the differential diagnosis at the bedside? Blanching: Intravascular vrs extravascular First, apply pressure to see if it blanches.  Dermatologists use glass and call it diascopy.  In the ED we…

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BOTFLY: OCCLUSION TEST

BOTFLY: OCCLUSION TEST

A patient recently presented with a subcutaneous nodule that appeared to be an abscess.  It was raised, erythematous, tender, indurated, and had a central plug…wait, no, it had a central hole.  And he just got back from Belize.  We put a transparent membrane on it to see if there was a creature in there.  Sure enough, a snout pushed at the membrane, seeking air.  This established the diagnosis – myiasis, secondary to a bot fly bite. Trying to remove that…

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OSTEOMYELITIS IN THE CHRONIC WOUND

OSTEOMYELITIS IN THE CHRONIC WOUND

A patient presents with a chronic diabetic heel ulcer that has worsened over the past few weeks.  Could this be osteomyelitis? It turns out that physical examination findings can significantly raise or lower the probability of this diagnosis. According to JAMA’s rational clinical examination series (Butalia 2008), 2 findings on physical examination have more powerful likelihood ratios than MRI: -A crater breadth of 2 square cm or more has a positive LR of 7.2. -Probing to bone has a positive…

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