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Emergency Medicine: Evaluation of Skin Disorders

Overview

Skin complaints account for a significant proportion of emergency department (ED) visits. The approach requires systematic assessment using lesion morphology, distribution, and associated systemic features to determine urgency, diagnosis, and treatment.

1. Initial Assessment: Is This Life-Threatening?

Before characterizing the rash, rapidly screen for:

Fever + petechiae/purpura - meningococcemia, Rocky Mountain spotted fever (RMSF), sepsis
Skin sloughing/blistering + mucous membrane involvement - Stevens-Johnson Syndrome (SJS) / Toxic Epidermal Necrolysis (TEN)
Widespread erythroderma - drug reaction, staphylococcal scalded skin syndrome (SSSS), TEN, toxic shock syndrome
Necrotizing soft tissue infection - severe tenderness, skin necrosis, gas in tissues
Anaphylaxis - urticaria + angioedema + hemodynamic instability

2. Key History (OLDCARTS-adapted for skin)

Element	Ask About
Onset	Sudden vs. gradual; hours vs. days
Location	Where did it start? Spreading pattern?
Duration	Acute vs. chronic (>6 weeks)
Character	Itchy? Painful? Burning?
Associated symptoms	Fever, joint pain, mucosal involvement, lymphadenopathy
Relieving/aggravating	Sun, heat, medications, contact agents
Recent exposures	New medications (especially antibiotics, sulfonamides, anticonvulsants), travel, sick contacts, insects, plants
PMH	Atopy, immunosuppression, HIV, autoimmune disease, malignancy

3. Primary Lesion Morphology - the Core Framework

Classifying by the primary lesion type drives the differential:

Lesion Type	Definition	Key Differential
Macule	Flat color change, <1 cm	Drug eruption, viral exanthem, meningococcemia (early), syphilis (secondary), vitiligo, cellulitis (early)
Patch	Flat color change, >1 cm	Tinea versicolor, port wine stain, fixed drug eruption
Papule	Raised, solid, <1 cm	Acne, warts, molluscum, urticaria, scabies, psoriasis, varicella (early), gonococcemia
Plaque	Raised, flat-topped, >1 cm	Psoriasis, eczema, tinea corporis, seborrheic dermatitis, urticaria, syphilis (secondary)
Nodule	Solid, deep, >1 cm	Furuncle, erythema nodosum, basal cell/squamous cell carcinoma, melanoma
Wheal	Transient, edematous, pale center	Urticaria, angioedema, insect bites, erythema multiforme
Vesicle	Fluid-filled, <1 cm	Herpes simplex/zoster, varicella, contact dermatitis (Toxicodendron), impetigo
Bulla	Fluid-filled, >1 cm	Bullous pemphigoid, pemphigus, SJS/TEN, burns, bullosis diabeticorum
Pustule	Pus-filled blister	Acne, folliculitis, herpes (zoster/simplex), impetigo, gonococcemia, psoriasis (pustular)
Petechiae	Non-blanching, <3 mm	Thrombocytopenia, vasculitis, RMSF, meningococcemia, endocarditis
Purpura	Non-blanching, >3 mm	Leukemia, coagulopathy, vasculitis, ITP, meningococcemia
Ulcer	Loss of epidermis + dermis	Pressure injury, arterial/venous ulcer, pyoderma gangrenosum, syphilis

4. Secondary Changes

These modify primary lesions and inform chronicity:

Scale - papulosquamous disease (psoriasis, seborrheic dermatitis, tinea)
Crust - dried serum/pus (impetigo, eczema)
Lichenification - thickened, hyperpigmented skin from chronic rubbing (atopic dermatitis)
Excoriation - linear scratch marks (scabies, pruritus)
Atrophy - thin, wrinkled skin (steroid overuse, lichen sclerosus)
Fissure - linear crack in skin (tinea pedis, hand eczema)
Maceration - white, soggy skin in skinfolds (candidiasis)

5. Distribution Patterns and Their Clues

Distribution narrows the differential significantly:

Distribution	Think of
Trunk + Herald patch	Pityriasis rosea (follows skin tension lines - "Christmas tree" pattern)
Extensor surfaces (elbows, knees)	Psoriasis
Flexural/intertriginous	Candidiasis, inverse psoriasis, intertrigo, hidradenitis suppurativa
Dermatomal (unilateral)	Herpes zoster
Palms + soles	Secondary syphilis, RMSF, hand-foot-mouth disease, scabies
Centrifugal (face > trunk)	Smallpox (historical), erythema multiforme
Centripetal (trunk > extremities)	Varicella
Sun-exposed areas	Photodermatitis, SLE, pellagra
Perioral/genital	HSV, syphilis, Behcet's disease

6. Skin Disorders by Region: ED Approach

Trunk

Papulosquamous disorders: Psoriasis (silvery scales, Auspitz sign, Koebner phenomenon), pityriasis rosea (herald patch, follows skin tension lines), tinea corporis (annular, scaly), tinea versicolor ("spaghetti and meatballs" on KOH - Malassezia), seborrheic dermatitis, lichen planus, secondary syphilis
Blistering disorders: Bullous pemphigoid, pemphigus vulgaris, contact dermatitis
Morbilliform eruptions: Drug reactions, viral exanthems

Groin and Skinfolds

Tinea cruris - symmetric annular erythematous scaly plaques; treat with topical antifungals x 1-6 weeks
Candidiasis - erythema + satellite pustules + maceration; predisposing: diabetes, obesity, antibiotics; treat with topical azoles; oral fluconazole if recalcitrant
Scabies - pruritic papules, burrows (thread-like lines with terminal black speck); interdigital clefts, waistband, axilla; treat with permethrin cream; ivermectin for immunocompromised
Inverse psoriasis - well-demarcated salmon-colored plaques without scale

Extremities

Erythema nodosum, erythema multiforme, psoriasis, diabetic skin findings (necrobiosis lipoidica, acanthosis nigricans, bullosis diabeticorum, diabetic dermopathy)

7. Cutaneous Manifestations of Sepsis

Per Tintinalli's, skin findings in sepsis include:

Direct bacterial involvement - cellulitis, erysipelas, fasciitis
Hematogenous seeding - petechiae, pustules, ecthyma gangrenosum
Hypotension/DIC - acrocyanosis, peripheral necrosis
Intravascular infection - microemboli, immune complex vasculitis
Toxin-mediated - toxic shock syndrome (TSS)

Always examine skin for a necrotizing or surgical source in undifferentiated sepsis.

8. Skin Conditions as Markers of Systemic Disease

From Rosen's Emergency Medicine:

Cutaneous Finding	Systemic Association
Acanthosis nigricans	Insulin resistance, type 2 diabetes, internal malignancy
Necrobiosis lipoidica	Diabetes (pretibial, yellow center, atrophic)
Purpura/petechiae	Thrombocytopenia, leukemia, vasculitis, RMSF, endocarditis
Pruritus (without rash)	Liver disease, renal disease, Hodgkin lymphoma, polycythemia vera, carcinoid
Generalized erythroderma	Drug reaction, SSSS, TEN, erythema multiforme, malignancy
Skin metastases	Breast, lung, GI, ovary, lymphoma/leukemia (poor prognosis)

9. Bedside Diagnostic Tools in the ED

Test	Indication	Finding
KOH preparation	Suspected fungal infection	Hyphae (dermatophytes), "spaghetti and meatballs" (Malassezia)
Tzanck smear	Suspected herpes (HSV/VZV)	Multinucleated giant cells
Wood's lamp	Tinea capitis, porphyria, vitiligo	Bright green fluorescence (Microsporum), coral-red (Corynebacterium)
Skin biopsy	Diagnosis uncertain or critical (vasculitis, SJS, pemphigus)	Histopathology
Punch biopsy	Deep dermal/subcutaneous pathology	Standard technique in ED

10. Disposition Principles

Situation	Disposition
Necrotizing fasciitis, SJS/TEN, septic shock	Immediate admission, ICU level care
Generalized erythroderma, Stevens-Johnson	Urgent admission
Anaphylaxis	Observe minimum 4-6 hours; admission if severe
Localized skin infection (cellulitis, impetigo)	Outpatient with antibiotic Rx; admit if systemic signs
Scabies, tinea, mild eczema	Discharge with treatment + follow-up

11. High-Yield Emergency Dermatology Entities

Condition	Key Features	Treatment
Meningococcemia	Petechiae → purpura, fever, sepsis	Ceftriaxone IV immediately
RMSF	Petechiae starting at wrists/ankles, spreads centrally, fever	Doxycycline (do not delay pending confirmatory tests)
Necrotizing fasciitis	Rapidly spreading infection, extreme pain, skin necrosis, crepitus	Surgical debridement + broad-spectrum antibiotics
SJS / TEN	Mucous membrane involvement, skin sloughing, bullae, <10% BSA (SJS) vs >30% BSA (TEN)	Supportive care, stop offending drug, ophthalmology, consider burns unit
SSSS	Children; superficial blistering + Nikolsky sign, no mucosal involvement	Antistaphylococcal antibiotics (nafcillin, cloxacillin)
Toxic shock syndrome	Diffuse erythroderma ("sunburn" rash), fever, hypotension, multiorgan failure	IVF resuscitation, antibiotics, source control
Erythema multiforme	Target lesions (3-zone concentric rings), acral distribution, herpes-associated	Supportive; treat underlying cause (acyclovir for HSV)

Sources:

Tintinalli's Emergency Medicine: A Comprehensive Study Guide, Chapters 234, 248, 251, 252
Rosen's Emergency Medicine: Concepts and Clinical Practice, Chapter 107 (Skin Conditions Associated with Systemic Disease)

Among these which are dermatological emergencies

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Excellent - I now have rich, detailed content from both Andrews', Rosen's, and Tintinalli's on all 6 dermatological emergencies. Here is the complete focused answer:

Dermatological Emergencies

From the conditions listed, the following 6 are true dermatological emergencies - they carry significant mortality if not recognized and treated immediately in the ED.

1. Meningococcemia

Causative organism: Neisseria meningitidis (gram-negative diplococcus)

Who is affected: Children <2 years (highest risk), adolescents/young adults 16-21 years; fatal in ~10% of cases

Clinical progression:

Early: Fever, malaise, leg pain, cold hands/feet, pallor/mottling - these precede the rash
Rash appears in ~50% as the first classic symptom - begins as nonspecific macules, rapidly evolves to petechiae (1-2 mm, discrete, non-blanching, trunk and lower body, soft palate, conjunctiva)
Petechiae coalesce into purpura and ecchymosis
~10% develop Waterhouse-Friderichsen syndrome: shock + massive intracutaneous hemorrhage + adrenal failure

Workup: Blood cultures, CSF cultures, skin scraping cultures; CBC (thrombocytopenia + leukocytosis)

Treatment - do not delay:

Ceftriaxone or cefotaxime IV (3rd-generation cephalosporin) + vancomycin
Add dexamethasone if meningitis suspected
Treat shock aggressively

The petechial rash directly reflects the degree of thrombocytopenia and DIC potential. Early identification is essential - progression to fulminant DIC/sepsis can occur within hours.

2. Rocky Mountain Spotted Fever (RMSF)

Causative organism: Rickettsia rickettsii - tick-borne (many patients deny tick exposure)

Geography: Despite name, most US cases are from the southeastern United States

Clinical course:

Abrupt onset: headache, high fever, nausea/vomiting, myalgias, chills
Disease lasts up to 3 weeks; can involve CNS, heart, lungs, kidneys, cause DIC or shock

Rash (appears day 2-6):

Starts as blanching erythematous macules at the wrists and ankles
Spreads centripetally up extremities to trunk and face
Becomes petechial or hemorrhagic
Palms and soles involvement is characteristic

Diagnosis: Clinical only in the ED - Weil-Felix reaction and immunofluorescence are not available acutely

Treatment - initiate on clinical diagnosis alone:

Doxycycline - drug of choice; failure to treat promptly dramatically increases morbidity and mortality
Chloramphenicol for tetracycline-allergic patients or children <9 years
Avoid: sulfa drugs (worsen disease), penicillins, cephalosporins, aminoglycosides, erythromycin (all ineffective)

3. Necrotizing Fasciitis

Pathology: Acute necrotizing infection of the fascia, with rapid progression to gangrene

Microbiology:

Type I (polymicrobial): Mixed aerobic/anaerobic bacteria (most common)
Type II (monomicrobial): Group A Streptococcus or community-acquired MRSA

Progression timeline:

Hours 0-48: Redness, pain, and edema
By 48 hours: Central dusky-blue discoloration ± serosanguineous blisters
Day 4-5: Purple areas become gangrenous
Key sign: Anesthesia of the involved skin (due to nerve destruction)

Red flags (LRINEC score components): Elevated CRP, leukocytosis, low Hb, hyponatremia, elevated creatinine, hyperglycemia

Diagnosis:

MRI is most definitive imaging (detects fascial plane involvement)
Bedside finger test: 2-cm incision to fascia - lack of bleeding, murky "dishwater" discharge, and lack of resistance to probing finger = positive
Soft tissue gas on plain X-ray or CT is pathognomonic when present

Treatment:

Immediate surgical debridement - this is non-negotiable and life-saving
Broad-spectrum IV antibiotics: vancomycin or linezolid + piperacillin-tazobactam OR carbapenem OR ceftriaxone + metronidazole
Supportive ICU care
Mortality ~20% even with optimal management; poor prognosis: age >50, diabetes, truncal involvement, diagnosis delayed >7 days

4. Stevens-Johnson Syndrome (SJS) / Toxic Epidermal Necrolysis (TEN)

Classification by % body surface area (BSA) epidermal detachment:

Entity	BSA Detachment
SJS	<10%
SJS-TEN overlap	10-30%
TEN	>30%

Common causative drugs: TMP-SMX, sulfonamides, lamotrigine, carbamazepine, allopurinol (most common in Europe), nevirapine, NSAIDs, penicillins, other anticonvulsants; acetaminophen in children

Genetic risk: HLA-B*1502 (Han Chinese and other Asians) strongly associated with carbamazepine-induced SJS/TEN - HLA typing recommended before starting carbamazepine in Asian patients

Clinical presentation:

Prodrome: Fever + influenza-like symptoms 1-3 days before skin involvement
Skin: Deep-red/dusky macules on face and trunk, rapidly spreading over 4 days; central desquamation, bullae formation, then sloughing
Mucosal involvement is hallmark of SJS - ≥2 surfaces: oral mucosa (hemorrhagic crust, erosions), conjunctiva (photophobia), urogenital, respiratory
Nikolsky sign positive: lateral pressure on skin causes epidermal sliding

Complications: Ocular scarring (most common long-term sequela), cutaneous scarring, vision loss, sicca syndrome, nail/hair abnormalities

Treatment:

Immediately stop the offending drug (single most important intervention)
Admit to burns unit or ICU
Supportive care: fluid/electrolyte replacement, wound care, temperature management
Ophthalmology consult urgently (ocular involvement is the main determinant of long-term morbidity)
Cyclosporine has emerging evidence for benefit; IVIg/TNF-alpha antagonists under investigation
Do NOT use systemic corticosteroids (controversial; most evidence suggests harm)

SCORTEN Score - predicts mortality in TEN (scores 0-7 based on: age >40, malignancy, HR >120, initial BSA >10%, BUN >10 mmol/L, serum glucose >14 mmol/L, bicarbonate <20 mmol/L)

5. Staphylococcal Scalded Skin Syndrome (SSSS)

Causative organism: Phage group 2 exotoxin-producing Staphylococcus aureus (exfoliative toxins A and B cleave desmoglein-1)

Who is affected: Primarily children ≤6 years (neonates most vulnerable); rarely immunocompromised adults

Clinical progression:

Erythema + crusting around the mouth (perioral)
Erythema spreads down the body
Bulla formation and superficial desquamation
Mucous membranes are SPARED (key distinction from SJS/TEN)
Clinical resolution in 3-7 days after appropriate treatment

Key distinction from TEN:

SSSS: Cleavage is intraepidermal (superficial, at the granular layer) - caused by hematogenously spread exotoxin, mucosa spared
TEN: Cleavage is at the dermoepidermal junction (full thickness) - caused by drug reaction, mucosa involved

Treatment:

IV antistaphylococcal antibiotics: nafcillin, oxacillin, or vancomycin (if MRSA suspected or penicillin allergic)
Alternatives: clarithromycin, cefuroxime
Fluid/electrolyte support; wound care (gentle, as skin is fragile)

6. Toxic Shock Syndrome (TSS)

Causative organisms:

Staphylococcus aureus (TSST-1 superantigen) - ~50% menstrual-associated
Streptococcus pyogenes (streptococcal TSS - often more severe, higher mortality)

Associations: Tampon use, surgery, burns, postpartum, osteomyelitis, fasciitis, abscesses, pharyngitis

Diagnostic criteria (all 4 required):

Temperature ≥38.9°C
Systolic BP ≤90 mmHg
Rash
Involvement of ≥3 organ systems (GI, muscular, CNS, renal, hepatic, hematologic)

Rash characteristics:

Diffuse, blanching, macular erythroderma - like a "sunburn" rash
Accompanying non-exudative mucosal inflammation (pharyngitis with "strawberry tongue," conjunctivitis, vaginitis)
Rash fades within 3 days
Followed by full-thickness desquamation of palms and soles (1-2 weeks later)

Treatment:

Aggressive IV fluid resuscitation
Vasopressors if refractory hypotension
Ventilatory support as needed
Remove source of infection (remove tampon, drain abscess, debride infected wound)
Antibiotics: anti-staphylococcal agent (nafcillin/vancomycin) + clindamycin (to suppress toxin production)
Consider IVIG for severe streptococcal TSS

Quick Comparison: The 6 Emergencies at a Glance

Emergency	Key Skin Finding	Mortality Risk	Immediate Action
Meningococcemia	Petechiae → purpura (non-blanching, trunk)	~10%	Ceftriaxone IV stat
RMSF	Blanching macules → petechiae, wrists/ankles first, palms/soles	High if delayed	Doxycycline stat (clinical diagnosis)
Necrotizing Fasciitis	Dusky skin → gangrene, anesthesia, crepitus	~20%	Surgical debridement + broad-spectrum ABx
SJS/TEN	Mucosal erosions + skin detachment, Nikolsky+	TEN: 30-50%	Stop causative drug, burns/ICU care
SSSS	Superficial blistering + desquamation, mucosa spared, perioral	Low in children	IV antistaphylococcal ABx
TSS	Diffuse erythroderma + desquamation palms/soles	Significant	Source control + clindamycin + vancomycin

Sources:

Tintinalli's Emergency Medicine: A Comprehensive Study Guide, Chapter 142 (Meningococcemia)
Rosen's Emergency Medicine: Concepts and Clinical Practice, Chapter 107 (Necrotizing Fasciitis, Meningococcal Infection, RMSF, SSSS, TSS)
Andrews' Diseases of the Skin: Clinical Dermatology, Chapters 6 (SJS/TEN), 14 (Necrotizing Fasciitis), and the Meningococcemia section

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