Invictus Reviews
Get ready for something new in the board review universe! A free podcast featuring the legendary Mel Herbert and crew. We're diving into the essentials for crushing the Emergency Medicine board exams—whether you're just starting out or mastering the advanced stuff. Brought to you by the same brilliant minds behind EM:RAP, CorePendium, and UCMax. 🚀
Coming soon to: Invictus.reviews
Invictus Reviews
Vesicular, Bullous and Sloughing Rashes - A call for feedback
Ok - this is a simple one - a great talk with a link to YouTube - we need your feedback. Go watch the lecture and give you you feedback here on on the YouTube channel please :). Feedback can also go to: mel@emrap.org
YouTube Link here
you, you, you're my people of the invictus, um. I want to encourage you to help me out here. So this is one of the first videos actually videos I know you're listening on audio. It's one of the first videos we created for invictus. It's with gita pencer, who has been an e-addoc for I don't know 20 plus years, quite famous and um, a spectacular. She's on UC Mac. She has her own litigation program. She's the bomb.
Speaker 1:So this is a talk that's dermatology, and although I'm going to add the audio here, I think you're mostly going to find it useless. And so really, what this is about is asking you to click on the link to the YouTube video, because I really want to start to get some feedback about these videos before we go and make a ton of them, and particularly about are they big enough? The style I'm doing a different type of emphasis during this video, so I want to get your feedback. You can email me at mel, at mraporg, to give me that feedback. I'd really really like it. Okay, but if you're like me, I'm actually one of those people that doesn't actually need to see the visuals to learn stuff, so you can also listen to this as well.
Speaker 1:There's a lot of pearls about some of these bullous, sloughing, horrible skin diseases that come up on exams and in life. But please, please, click on the link below. Take a look at that YouTube video and give us some feedback, because we're about to get busy and I want to make sure that we are hitting the high points, as it were. Herbia, and actually what I really need is a core group of residents and program directors that will give us ongoing feedback as we develop this, and you'll get all this crap for free. We don't need a lot of you, but if you're interested and if you're interested enough to give us feedback as we create this stuff, a lot of free stuff coming your way, because we would use you as beta testers. So talk to me. Melodammraporg.
Speaker 2:All right, we are going to talk about vesicular, bullous and sloughing rashes. It's morning right now. This is a great way to start my morning, all right. So let's hit vesicular rashes first. All right, so vesicular rashes. What we're going to hit are herpes simplex 1 and 2. We're going to take a look at varicella or chickenpox herpes zoster, which is as we all know, and we'll talk about sort of a late life transition of varicella hand, foot and mouth disease contact dermatitis, because they also have vesicles and then a little bit about something called dermatitis herpetiformis that people may not know too much about, but I just want to mention it in case it comes up, because it is a rash that is increasing in prevalence. So we'll talk about that. How about that? All right, yeah, how about we start with herpes simplex virus?
Speaker 2:Mel, you and I did a segment on UC Max about herpes simplex, so I think this is just a thing we have. We like to talk about herpes. Well, it was a good segment, by the way, all right, so we're going to do the 10,000 foot view of it, though here instead of like the super deep dive. But basically, there are types one and types two of herpes simplex virus that affect people and they typically cause the mucocutaneous infection.
Speaker 2:So historically we've thought of HSV-1 as the one that causes cold sores. Right, we thought HSV-1 caused herpes labialis and we thought of HSV-2 as the one that caused genital herpes. The truth is now it's getting to be much. There's much more crossover now, and so you can't reliably say that one is HSV-1 and one is HSV-2. If you wanted to know that, you would have to do a PCR culture. So either way, they cause these painful, blistering rashes. The first episode of either labial or genital herpes simplex can be accompanied by fever or systemic illness, and the thing about these things is that they tend to recur. Actually, mel, I remember the joke that you told from our segment, which was what's the difference between love and herpes?
Speaker 1:Herpes lesboro.
Speaker 2:Lesson learned, all right. So there are other sites of infection that we should know about where herpes simplex can infect us. It can give us a meningitis encephalitis. People have probably heard about herpes encephalitis. That could be a big deal, and they may not have the rash accompanying it. So you're going to have to do all the appropriate testing, cultures et cetera, to find out Skin you can have.
Speaker 2:You know, wrestlers get herpes gladiatorum, like there are other places you can get it herpetic, wit, low-usery picture that in a second Gladiatorum. Yeah, I'm pretty sure I'm right about that. Now I have to look that up. But yeah, no, herpes gladiatorum is the one the wrestlers get. Skin on skin. You can have visceral organs when you're, usually if you're immunosuppressed, hsv keratitis is something that you should be able to recognize, and those dendrites are the hallmark, the dendrites that you see on a fluorescein examination. This can cause blindness if it's not recognized early, and so you know it could be this, it could be herpes zoster keratitis when you see those dendrites. Either way, you're going to get ophthalmology involved as soon as possible, all right, any questions on that? Mel?
Speaker 1:No, I don't think there's any questions. But herpes simplex 1 and 2 can occur anywhere. The primary event can be quite severe antivirals. If you get them early and then in the eyeball bad, it's potentially eye-threatening. Got to make the diagnosis Dendrites, lots of eye drops, ophthalmology Got it.
Speaker 2:Herpes labialis. Here's a picture. As I said, often HSV-1. Many people acquire this in childhood. The vast majority of people across the world have antibodies to it. Not everybody gets cold sores, just the lucky ones. I guess Tons of asymptomatic carriers help spread this, exacerbated by stress, illness, sun. There's an association between erythema multiforme and herpes simplex. That, just if those come up on the boards, just remember that they go together somehow.
Speaker 1:And we should say that the first episode of herpes in kids, herpes, stomatitis, can be really bad. They can't eat, they can't drink. Sometimes they have to be admitted and then that'll go away and they might have recurrent herpes or they may not. They may be asymptomatic spreaders, they may not.
Speaker 2:That is the whole problem with herpes. There are a lot of people walking around who are at least asymptomatic and just spreading the love and the herpes, yeah and so, yeah, exactly A first time episode. You may have a significant systemic illness. And these poor kiddos, when you see them with their herpes gingivostomatitis. First of all, there's lots of questions to answer to the parents about. Like no, it's healthy.
Speaker 2:Man presents with vesicular lesions on the penis. Symptoms began three days ago with fever, malaise, lymphadenopathy, followed by the development of the rash, and the patient reports recent sexual activity without the use of barrier contraception. So this is what you're going to see. You may see pictures that accompany it. This one is a perianal genital herpes breakout. This is a pretty substantial ulcer and so, remember, when the vesicles pop, they can leave ulcerations and the whole thing is quite painful. This is herpetic Whitlow. So when I was saying there's different names for herpes on the skin, what is the? I put it in red Mel. So I think it's okay to ask you what is the main thing to remember about herpetic witlow?
Speaker 1:Keita's laughing because I said don't ask me any questions. I don't know any derm. But herpetic witlow, you do not want to stab it. And it looks like it's a felon, it looks like it needs to be IND'd. But if they've got those vesicles on there, they've got the story in there. Don work, it's a classic foil on the test. They'll show you a picture and say want to IND this? And the answer is and no, I don't.
Speaker 2:So a general rule of thumb of mine is not to touch things without gloves. That's a good rule. Okay, here's something that you should recognize. This is called eczema herpeticum. Terrible eczema can get super infected by really almost any germ bacteria. You'll see, obviously, staph and strep infections too, but eczema herpeticum is something to really know about, because this can cause this can, because this can require hospitalization. These kids can get really systemically ill. So recognize it when it's eczema a child who has a history of eczema. So recognize it when it's eczema a child who has a history of eczema. It looks infected and you see painful blisters. If you see vesicles and you've really got to think about it and they're going to need to be treated with antivirals, all right, let's move on to varicella. Okay, so have you seen? You're old enough to have seen chickenpox Back soon. I'm becoming back soon, right? So vaccination rates, wayne. We are seeing chickenpox more, and so it's important to be able to recognize it. The vaccine overall really did reduce the incidence.
Speaker 2:Same sort of thing with all these viral stuff. You've got this prodrome fever, malaise, and then you get this classic rash which comes out not all at once, it usually spreads centripetally, and so the lesions are in separate stages. Whenever you see this person, which is an important distinction from smallpox I doubt they'll ask you about smallpox. But smallpox can look like this, but everything comes out all at once, just FYI. But smallpox can look like this, but everything comes out all at once, just FYI.
Speaker 2:So this classic dew drop on a rose petal thing is this looks like this is chickenpox. So you've got this red little area, tiny, little discrete lesion, and then the dew drop is the vesicle, which will then pop and then crust over. And so again lesions in different stages, very itchy that's a hallmark. These are more itchy than painful. Usually they can get super infected. So if you have a few that are getting because they scratch them so much, if they're getting really red, with spreading redness from it and actual pus drainage from the vesicles or anything like that, then you may be dealing with a super infection. They'll turn into those sterile pustules. Usually they'll look a little opaque inside and then they scab over, and those scabs last a couple of weeks and when they're all scabbed over, that is when that person is no longer contagious with chickenpox.
Speaker 1:Okay, okay. So central out itchy, itchy Dew drop on a petal rose petal and hangs around for a few weeks can get super infected. Yeah, smallpox was the big thing that this was differentiated from, but there hasn't been a case of smallpox since 1979, I believe, which is just one of those amazing public health things you need to worry about.
Speaker 2:Okay. So varicella people do get breakthrough cases, but they're usually very mild, just a few vesicles. So if you see something like that with a few dew drops and rose petals, it's probably a breakthrough case. I don't think they're going to ask you about a breakthrough case on the board, but you should probably know about it. Also, you should know that the immunocompromised and neonates are more susceptible to severe illness, like with just about everything. But they may get the pneumonia encephalitis, some kind of super infection. They can get hepatitis.
Speaker 2:Rise syndrome was first really, as my understanding was, was first really discovered as an association between children's aspirins and chickenpox. But they can develop RISE. And so unprotected patients meaning they don't have antibodies at high risk of complications, who present within 10 days of exposure, should be given the varicella zoster immunoglobulin. Okay, so if they are at risk or they're not properly immunized and they're coming within 10 days of exposure, they ought to get the immunoglobulin. So who are high-risk patients for varicella? Pregnant women without evidence of immunity. So you could actually test their titer and see if they're immune and if they're not, then they're going to need the immunoglobulin if they're exposed. Immunocompromised patients who don't have any evidence of immunity. Newborns so it was between five days prior to or 48 hours post-delivery Any premature babies and, by the way, all these people can get primary chickenpox from shingles from herpes zoster. So that's important. If they've been around a person with shingles and they're not protected from chickenpox, they can get primary chickenpox. So they are going to need the immunoglobulin, okay, okay.
Speaker 1:That's a really, really important point. Shingles is infectious. Yes, shingles is infectious, and if that person is around a low a high risk person, that person should get immunoglobulin if they're not priorly infected.
Speaker 2:Good point and that person should get immune globulin if they're not priorly infected. Good point, ta-da, okay, so here's a picture of it. This is drastic shingles. I think this is great. So you see, okay. So shingles again grown up, varicella coming back again. It sort of lives dormant in the nerve roots and then decides to come out, oftentimes in periods of stress or when you have an important event coming up that you don't want to have shingles for.
Speaker 2:And so classically what you'll see is this dermatomal distribution that's kind of how you know usually is that you'll see it it, just it takes up a dermatome. Now it can be systemic. In immunocompromised people, people with low immune systems, people who are in chemotherapy, they can get systemic shingles. And so if you we call it systemic, if they've got three or more dermatomes involved, if it starts crossing the midline it's not really supposed to cross very far over the midline you can also get complications of pneumonia, encephalitis, and so again, the mainstay of treatment here antivirals. You're going to start them early in the course, early if possible, to try and prevent post-herpetic neuralgia. There's some debate whether you should bother after the first three days, but I tend to treat. If they're uncomfortable. I tend to try to treat them with the antivirals and pain management. They might need legit analgesia.
Speaker 1:Go over that rash again, because it's classically dermatomal, so it follows your dermatomes. It does not usually go across the midline. If it crosses the midline, think of something else. It can go a little bit, but your dermatomes really stop in the midline and it's usually just one dermatome or two dermatomes and, as we've heard here, if it's three or more, then this is sort of a big outbreak and maybe they're immunosuppressed or they're going to be pretty sick and it hurts. The other thing we should say is that it's often pain first before the rash, and so somebody will come in when you think they're having a splenic infarct or a renal infarct or something, because they have this deep, boring pain and then the rash comes. I don't know if they'll test it on the exam, but clinically, in the real world, that happens all the time. It's like I don't know what's going on. Have a really good look and see if there's a little tiny rest under there, some vesicles. That's where the pain's coming from.
Speaker 2:All right. So bad things about herpes zoster also that they can also wind up in the eye right, and there is a classic sign that they may ask you about on the boards that has a name to it they may be the harbinger of herpes zoster ophthalmicus, which is Hutchinson's sign. Hutchinson's sign.
Speaker 1:Yeah, so the tip of the nose has the same innovation as your cornea. So if you see vesicles on the tip of the nose, it suggests it's in the cornea. Am I getting this right?
Speaker 2:You got it right. You've got it right. So if you see that, so it may spread then to create a keratitis. So if you see that and you're diagnosing shingles, just know that the eye is at great risk. If it's not at great risk, you should examine the eye on a fluorescein, but if you don't notice anything yet, you still should be getting that person to see an ophthalmologist quickly. Ramsey-hunt is another one of these named syndromes associated with zoster, and this is where they get shingles in the ear and so it's affecting the geniculate ganglion. It can cause ear pain, a bell palsy Vesicles in the ear canal is the tell, so you're going to have to look, and it can also be associated with hearing loss, tinnitus or dizziness. And so you should always look in the ear when somebody has unilateral facial weakness, because then you could be the hero that diagnoses Ramsey Hunt.
Speaker 1:They love the complications on the exams. So if it's on the nose, into the eyeball, hutchinson's sign drops lots of antivirals, call ophthalmology. If it's in the ear ball, then it is the Ramsey Hunt syndrome and same thing. They're going to treat them aggressively and you get them followed up. So it's the complications of these zosters the one that goes into the eyeball, the one that goes into the earball. The eyeball one is the worst one.
Speaker 2:So our goals are to treat early to prevent post-hepatic neuralgia, which is a big problem. The shingles gets better but the pain doesn't go away and the pain is bad. So we'd like to reduce that if we can, and so early treatment might be able to help with that. We want to prevent super infection if we can. So we're telling people like not to muck with it too much, right? And if there's pain we treat the pain. So antivirals, analgesics, if needed, consultations.
Speaker 2:If you've got eye or ear involvement or disseminated cases are going to need to come into the hospital for intravenous antivirals and lots of consultations. So obviously, if there's CNS involvement, which does happen, or they're severely immunocompromised, disseminated, these are phone calls you're going to be making to the people who are taking care of them, that kind of thing. Those are much higher levels of management. So just recognize they can be quite sick.
Speaker 2:Let us move on to hand, foot and mouth, which can cause vesicles, right? So here is a classic case out of Corpi Two-year-old male presents, with refusal to eat and fussiness he is found to be, which sounds like a lot of two-year-olds actually, but they only eat white things only, I know. But this one won't even eat popsicles or white items, so presents with refusal to eat and fussiness. He's found to be febrile to 38.3, with a punctate, painful vesicular rash in his mouth and a non-tender rash on his hands and feet, all with an erythematous base. All right, so this is you're getting the most classic case in which you actually get the rash and the mouth and there their hands and feet and mouths involved in a fever, and so you know, and hopefully that's what they would give you on the boards, even though we know in real life, like you probably have, like one of the spots involved.
Speaker 1:It should be called hand, foot, mouth and butt disease.
Speaker 2:Yeah, it does hit the butt a lot of the time, right? So maybe they try to fool you by showing a picture of the butt and you're thinking like I don't know a hand, foot, mouth, butt disease, so just know that that is a thing. So the rash can be. You know you can't count on the rash looking like a certain kind of rash. So the mouth is usually vesicular and that's going to be a tell. Or if they pop you'll see tiny little ulcers. But the rash itself on the hands and feet and butt can be macular or papular, it can be vesicular, it could be a combo, special, who knows. So you're really looking for like a sick looking kid with these varieties of rashes and things in the mouth and a lot of times, if it's just the thing in the mouth and you know that it's going around, you're probably going to make that diagnosis anyway. But for the boards, I think they would help you out with an additional photo or something like that and then you would know that there's no specific treatment. It's really supportive care of this kid, All right.
Speaker 2:Contact dermatitis can also be vesicular often is vesicular right. So this is a classic. Very like. This is highly vesicular to me. Usually they're not quite as vesicular and they're like little vesiculars but it's like a little bit like smallpox and so you know. So this is sort of a classic thing. There's two types of contact dermatitis. There's irritant contact dermatitis and there's allergic. So irritant is because the thing itself is causing cytotoxic effects on the skin. This is not an immune mediated thing, this is just like a cellular insult from the actual thing. So detergent, solvents, things like that and that can create this sort of vesicular, linear. This is more. This picture, I think, is more classic. Classic.
Speaker 2:If they're going to show you a contact dermatitis, they're probably going to show you these linear vesicle kind of things. The allergic ones just know it's immune, mediated, this delayed hypersensitivity, so you're not going to get it the day of. It may be like the next day. So poison ivy, poison oak, those types of rashes. You're going to have a little lag and I bet the picture they're going to show you is going to look a lot like this the management, the main thing that they want you to know is that, well, for irritant dermatitis, you're going to treat it pretty much the same way, with some steroids and avoiding the thing, and if it's still on the skin.
Speaker 2:You want to get that off of there. Allergic is probably where they're going to focus their efforts. You're going to use topical soothing methods, antihistamines for the itch, topical steroids if it's not super widespread. If it's widespread, this is the thing. Yes, you're going to put them on oral steroids, but you need to keep them on there for like a long time, Like they need to be on them for like two to three weeks at least, because otherwise they will rebound. So that I feel like is the board's worthy thing to know.
Speaker 1:Remember the classic sort of metal bracelets, necklaces, earrings, classic things where you can get this contact dermatitis this contact dermatitis.
Speaker 2:Yeah, then you just develop a dermatitis. So, yeah, cheap jewelry stuff and nickel is usually the offending agent in that case and so, yeah, those are all going to be some cheap jewelry with nickel, right, you need the real bling. That's what you need, all right? Okay, so those are our vesicular rashes. Let's hit some bullous rashes, okay.
Speaker 2:So I mean, bullae are like they're basically big vesicles, right, it's derived from the Latin bubble, just so, just because now they're sort of bubbles, right, but basically they're, yeah, they're basically big blisters, right, they're usually over a half a centimeter and they can be flaccid or tense. So flaccid, like you like, just you know, if, just you know, if you poke at it, as opposed to tense, like that bubble's not going anywhere, it's a very it's like you know. You know, if you look at bubble wrap and the bubbles are nice and fresh, they're like tight bubbles versus like the half-light deflated, no fun bubble wrap, okay, so we're, they're hard to pop, all right. So we're going to hit Bullous, pemphigoid, pemphigus Vulgaris, and we'll talk about keeping those two things straight in your mind, because that's hard. I get them confused a lot. And Bullous Empatigo is another thing that's going to come out with Bullous, so Bullous Pemphigoid.
Speaker 2:This is chronic, autoimmune, usually older. So Pemphigus vulgaris is usually younger and they're gonna and they're sicker, right, this is sort of a chronic thing. It can be serious like it can be a real. You know it can be a life-altering disease. But um, usually older adults, very large tense blisters or bully um, it can be in one spot, it can be wide. Do you remember Nikolsky's sign?
Speaker 1:Wait, is that where the skin just sort of sloughs up? You can like push it yeah.
Speaker 2:Yeah, yeah. So it doesn't do that. And so you know, a lot of times you'll see it in these like intertriginous areas, flexor surfaces, and so first it's like a rash and then there's more blisters and vesicles and then you've got these big boy. And so this is going to be a referral to the dermatologist. They'll do all the biopsies and that kind of thing. But this person is not usually going to look ill. They'll do a biopsy. They might put them on NSAIDs and steroids. If they look systemically ill, like you're going to admit them because one, because you're going to be like this person's really ill with a blistering rash, I don't know what. This person's sick, they need to come into the hospital and they may get if it's really widespread, it's like it's almost like burns they're going to get these fluid and electrolyte imbalances and so they like can actually need ICU care when it's that bad. But that's rarer. Usually it's the sort of indolent chronic thing in an older person, as opposed to pemphigus vulgaris. So I just realized I remember vulgar is bad, right? So of the two of them, vulgar is bad, so pemphigus vulgaris is. I mean, I don't want either one of these, but like pemphigus vulgaris it might even be too old to get.
Speaker 2:Usually this is younger people or it can affect younger people. You can see it in older people, but if they're going to give you a classic case, it's going to be a younger person. So these are flaccid, thin blisters with a Nikolsky sign. You push that thing over and then the skin's just going to slough off right, and so skin, mucosal surfaces often a large body surface affected, and there's, again, a wide differential for any of these things. But they're going to look sick. So they're probably, if they're really sick, they're going to come into the hospital. Otherwise, they need dermatology soon because they're probably going to be on steroids and they need the biopsy, they need the follow-up. And so, again, if they're sick, if they're dehydrated which they can be if they're getting metabolic disturbances from the fact that their skin is all coming off and you tend to dissipate a lot of important fluids that way, they're going to need to come in and get care. But younger people, positive, nikolsky, vulgar, because it's bad, it's worse, so, yeah. So here's a picture Like the skin starts coming off, right, yeah.
Speaker 2:So autoimmune blistering, again, mucosal services, potentially fatal, right, this is like potentially fatal. So peak ages. They say 40 to 60. Like you know, even as young as 30, I think I've only seen it a couple of times it can be drug induced. They're going to have to do a lot of any of these blistering diseases. There's going to be a lot of workup when they're really sick to figure out like what is this? And we'll talk about some other things that slough, because this is sort of bullets into sloughing. We're going to talk about sloughing in a second, but you know this is something that's going to need like an all hands on deck situation. This is when dermatology needs to come in. They're not coming into the ER, but they're going to come to the hospital and they're going to see this person.
Speaker 2:Okay, bullous impetigo. These people are not quite as sick. They have impetigo but they have a staph that is giving off the same exfoliative toxins that cause scalded skin syndrome. So the same thing that kind of makes things sort of the skin start to separate from the dermis, so the lesions are usually going. Makes things sort of the skin start to separate from the dermis, so the lesions are usually going to be on the trunk or extremities localized vesicular eruption, then this fluid-filled bullae, and then it can rupture pretty easily and then these clusters of shallow erythematous lesions they leave like a scaly. That's classic scaly thing of impetigo.
Speaker 2:If you recognize impetigo from on the face, a lot of times you always see a picture of it between the nose and the lip, the honey crusting, that kind of thing. So there's going to be some honey crusting, but with bullae right. That's going to make you think of bullous impetigo, which is a subset of impetigo typically on the trunk. Impetigo typically on the trunk, and if it's superimposed on atopic dermatitis it can actually be a little more widespread. I don't think they're going to do that to you. I think that they would show you this picture of like a honey-crusted thing with a bulla somewhere on the torso of someone, probably relatively young, although this does happen in older people than you know.
Speaker 2:Impetigo Impetigo we think of as like little kids. You can see this in slightly older ages, but you're going to have to just go on the fact that they're not very sick. Okay, all right, and so okay. So now we're looking at bullets and patigo. You'll notice the bullae. There's some crusting with it. Person's not that sick. Talk about the sloughing rashes. None of these are good. I'll just say that at the outset, like if they're Be prepared, be prepared to do all the things.
Speaker 2:So we're going to talk about Staph scalded Skin Syndrome, which I alluded to a moment ago, toxic Epidermal Necrolysis, ten, and these guys are on a spectrum TEN and SJS, stevens-johnson Syndrome, sjs and so they all love the initial Staph Scalded Skin Syndrome. You would recognize this like okay, something is wrong here, right, and the skin does seem to be peeling off. So quadruple S. Staph scalded skin syndrome starts with a local infection with staph and then the toxins from the staph cause the skin cells to slough, and this is usually going to be newborns and young children. We don't tend to see this in adults. You can see that same toxin causing something like a bullous impetigo, but you don't see it the widespread whole body thing that you will see in the newborns and the little kids. And so this has a positive Mikulski sign with, you know, sloughing of the skin with just slight rubbing. So the things that have positive Mikulski signs tend to be like more, you know, the skin comes off much more easily, and so those are like pemphicus vulgaris, like it. Just it comes off right, which will leave you with a situation where you're gonna have to manage this. You know, if they get lots of electrolyte disturbances and things like that. So okay.
Speaker 2:So first they have the scalded skin. Now, in this skin tone you may not see it as scalded skin. In a child with lighter skin you might see that it looks erythematous first, and that's where the name comes from, and then you're going to see these like they're very fragile belay than the desquamation and so it can be just one part of the body. But I mean, when I've seen it it's been more generalized. One very important note, and for all of the sloughing diseases, anything that actually creates vesicles and things like that, always look in the mouth, always look at the mouth and the mucous membranes. You want to know, right, you want to know is this affecting the mouth? Because that sort of changes, your differential Staph scaldus skin syndrome, will not affect the mouth. It doesn't affect mucous membranes, unlike TEN. So they may be sick with it. They may have fever, chills, skin tenderness, malaise, irritability, so they'll have a systemic illness along with it, and also that differentiates it from impetigo when they're usually not that sick.
Speaker 1:Now this was a bit of a pearl for me. I don't remember knowing that Staph scalded skin syndrome does not affect the mucosa. I looked it up in a number of references. Most of them agree that it does not. Some of them say in severe cases it can even involve the mucosa. But in most of the cases it looks like that Staph Scalded Skin Syndrome, ssss, is differentiated from these other bullish conditions by the fact that it does not involve the mucosa.
Speaker 2:So flu is antibiotics. Clindamycin is an important pearl here too because clinda, even if you're going to give them other antibiotics, clindamycin stops the exotoxin formation, so it will stop the sloughing, it will or at least further sloughing. So if you can get rid of that exotoxin then that's gonna help the whole process. So you may be double, triple covering for all sorts of stuff, but you're gonna. But you want clinda is like the first thing that you're going to reach for. Um, and then local skin care, wound care. You're gonna admit them to the hospital Again, yeah, burn center type thing, okay.
Speaker 2:So TEN and SJS same disease continuum. They can cause severe mucocutaneous so yes, mucous membranes and cutaneous reactions and then necrosis and then the epidermis detaches, which just sounds awful. Some things to know is that medications can be a trigger for this, and so common ones are things like allopurinol, nsaids, aspirin, sulfa also associated with HIV and lymphomas and vaccines, and I don't think they're going to ask you that. I think they're going to make this a drug associated reaction. So the SJS is the less severe end of the spectrum reaction. So the SJS is the less severe end of the spectrum. What's an easy way to remember this? I don't know. 10 is like so oh, here, yeah, it's got a scale of 1 to 10. But 10, you have to remember that 10 is the worst. It's like the most severe manifestation is 10. So SJS is the less severe end of the spectrum. Usually less than 10% of the body surface area is affected and 10 is going to be more than 10. Actually, it's really more than 30 because there's this overlap. Why did they do this? There's an overlap SJS slash TEN overlap area between 10 and 30%. But so the more severe on a scale of 1 to 10, to 10, right, that's going to be the toxic epidermal necrolysis and the 10, right, that's going to be the toxic epidermal necrolysis and then less is going to be the SJS. Now this to me seems completely academic, because you're going to be watching the person with SJS to see if it evolves into TEN, and I get that you're going to be more aggressive with the person who has TEN, but you're still going to be nervous when you're looking at SJS, right?
Speaker 2:So you know, this is looking at the mouth. Here is, I think, the point to note. In this person you can see that there is some swelling and edema and this person has mucocutaneous involvement. You can also see some of the skin rash starting on the chest. This one is bad right. This is toxic epidermal neck. I mean like look at the skin, like this person, and you can tell by all the other things in the picture that this person is sick right.
Speaker 1:Yes, yes, yes, yes.
Speaker 2:So they're not. They're not well, and so they will also get a prodrome right, A flu-like thing maybe, a burning sensation in the eyes and the mouth. That means that this thing is coming. That's the harbinger of the mucosal involvement. You do get mucosal or conjunctival involvement in probably 90%. So that's going to be your tell like look in the eyes, look in the mouth mucositis, stomatitis, genital involvement. So you got to look at all those places and so then you're going to know if you start seeing them.
Speaker 2:The conjunctivitis might be your first clue, but it should make you pretty nervous and really just look at the drug list, all right. So yeah, so they can have all sorts of eye symptoms. So they could just have photophobia, right. But if they've got eye complaints, then pay attention to that. Purellian conjunctivitis. They can have bullae of their conjunctiva that sounds terrible Corneal ulcerations If they survive and they're very ill and their eyes were really affected. They can have long-term vision problems. So they're going to also need ophthalmology to come in and take a look at things. All right, and so last little bit here Just remember remove the offending medication If they've got more than 30% of their body surface involved. This is a true emergency. They're going to need ICU burn center care, lots of supportive care, fluid pain management and that is it for my sloughing, rashes and horrible diseases that nobody wants to be affected by Lecter.
Speaker 1:Thank you. Just a reminder of all the terrible things that can happen, the worst ones in the bible, right there oh yeah, yeah right, this is definitely an affliction, um so, but important to recognize.
Speaker 2:And so I think that really, for the board's purposes, like being able to identify the rash, putting it within a class of diseases and saying sick or not sick and then knowing generally, like antivirals or supportive care or icu or burn center or called rheatology, you need a biopsy like those. You know, those are the things I don't think they're going to ask like real nitty gritty stuff about it. It's going to be like what is this and how do you manage it?