Dr.

Muhammad Rashid

The rash and mucous membrane lesions shown

in the photograph
develop in an infant 5 days into the course of
an upper respiratory infection with otitis media,
being treated with amoxicillin. The childs
condition is likely
a. Urticaria
b. Rubeola
c. Stevens-Johnson syndrome
d. Kawasaki disease
e. Scarlet fever

Definition
Arashis a change of theskinwhich affects
its color, appearance ortexture.
A rash may be localized in one part of the
body, or affect all the skin.
Rashes may cause the skin to change
color,itch, become warm, bumpy,chapped,
dry, cracked orblistered, swell and may be
painful.

Viral Infection eg. Measels

Bacterial Infection such as Scarlet fever
Food Allergy
Other Allergies:

for example: dyes, medicines, insect stings, metals such as zinc

or nickel (such rashes are often calledhives)

Skin contact with an irritant

Fungal infection
Reaction tovaccination
Skin diseases such aseczemaoracne
Exposure tosun(sunburn) orheat
Ricketial disease eg Rocky mountain spotted fever
Coagulopathy as patachae or perpura eg. ITP
Vasculities eg kawasaki disease

It is a mild, self-limited rash

E M is a type of hypsersensitivity reaction. It occurs in
response to medicines, infections, or illness
Pink-red blotches, symmetrically arranged and starting on
the extremities. It often takes on the classical "target
lesion" appearance,with a pink-red ring around a pale
center. also called "iris", or "bulls-eye
May have vesiclesand blisters of various sizes (bulla)
Are located on the upper body, legs, arms, palms, hands, or
feet, May involve the face or lips
Resolution within 710 days is the norm
Medications that can cause this reaction include:
Barbiturates ,Penicillins Sulfonamides ,phenytoin
Infections include: Herpes simplex , Mycoplasma, leprosy ,
Fungi

Symptoms
Fever
Malaise
Itchingof the skin
Joint aches
Multipleskin lesions
Eye burning, itching, and discharge
Mouth sores
Tests include: Nikolsky sign, skin lesion biopsy and
Examination of skin tissue

Target lesions

Itis an immune-complexmediated hypersensitivity

disorder that typically involves the skin and the mucous
membranes.
StevensJohnson syndrome (SJS) is a milder form of
toxic epidermal necrolysis(TEN)with less than 10%
body surface area detachment
This Inflammatory disorder is triggered by anallergic
reactionto certaindrugsincluding antibiotics, such as
sulfonamides, tetracycline,penicillin and amoxicillin.
Nonsteroidal anti-inflammatory medications and
anticonvulsants such ascarbamezapine, velproate,
phenobarbital,diclofenac have also been implicated
Occurs up to 1-3 wks after drug exposure
common infections are- Herpes simplex virus, influenza,
mumps,EB virus,
histolpasmosis,mycoplasma,HIV,diptheria
Gp A strepto cocci.

Signs and symptoms

Productive cough, headache, fatigue, arthralgia, sore throat,

Ulcers in the mouth and lips but also in the genital and anal
regions.
Mouth ulcers are usually extremely painful and reduce the
patient's ability to eat or drink.
Conjunctivitisof the eyes occurs in about 30% of children
who develop SJS.
The rash can begin as macules that develop into papules,
vesicles, bullae, urticarial plaques, or confluent erythema
The typical lesion has the appearance of a target; this is
considered pathognomonic
In contrast to the typical lesions of erythema multiforme,
these lesions have only 2 zones of color

Targer lesion in SJS

Mainly clinical Diagnosis

It is a Dermatological emergency, mortality rate is 5%
Withdrawal of any agent suspected of causing the condition is
critically important
Oral lesions are managed with mouthwashes; topical anesthetics for
pain relief
Areas of denuded skin must be covered with compresses of saline or
Burow solution
Tetanus prophylaxis must be addressed
Treatment is similar to that for patients with thermal burns, and
continued care can only be supportive (e.g.intravenous
fluidsandnasogastricor parenteral feeding) and symptomatic
Consider Iv IG

It is a life threatening dermatologic disorder

Widespread erythema, necrosis, and bullous
detachment of the epidermis and mucous
membranes
Resulting in exfoliation and sepsis and/or death
Mucous membrane involvement can result in
gastrointestinal hemorrhage, respiratory failure,
ocular abnormalities, and genitourinary
complications.
TEN involves more than 30% of the body
surface, whereas SJS involves less than 10%

Erythema
Multiforme

Stevens
Johnson
Syndrome

Toxic Epidermal
Necrolysis

Lesion

Macules/papules with central

vesicles
Classic bull'seye pattern of
concentric light and
dark rings (typical target lesionsl
Bilateral and symmetric
All lesions appear within 72 h
May show dermal edema
Lesion "fixed" for at least 7 d

Cutaneous blistering with

mucous membrane
involvement
"Atypical lesions": red
circular patch with dark
purple centre (aka
targetoid)
"Sicker" (high fever)
Sheet-like epidermal
detachment in < 10%
(Nikolsky sign )

Severe mucous membrane

involvement, and blistering
"Atypical lesions": 50%
have no target lesions
Diffuse erythema then
necrosis and sheet-like
epidermal detachment in >
30%

Sites

Dorsa of hands and forearms

Mucous membrane involvement
(lips, tongue,buccal mucosal is
possible
Extremities with face > trunk
Involvement of palms and soles

Generalized with
prominent face and trunk
involvement
Palms and soles may be
spared

Generalized
Nails may also shed

Other
Complications

Burning and stinging

Recurrences
Secondary bacterial infection

Scarring, contractures,
eruptive nevomelanocytic
nevi, corneal scarring,
blindness, phimosis and

Tubular necrosis and acute

kidney injury, epithelial
erosions of trachea, death

Erythema
Multiforme

Stevens Johnson
Syndrome

Toxic Epidermal
Necrolysis

Constitutional
Symptoms

Weakness, malaise

Prodrome 1 -14d prior

to
eruption with fever and
flulike illness

High fever > 38C

Etiology

Infection: HSV, or
Mycoplasma
pneumoniae

Frequently drug related

(NSAlDs,
anticonvulsants,
sulfonamides,
penicillins)
Occurs up to 1 3 wks
after drug exposure with
more
rapid onset upon
rechallenge

Frequently drug related,

sulphonamide,
chlorumphenicol,
penicillin,allopurinol etc
< 5% are due to viral
infection, immunization

Differential
Diagnosis

Giant urticaria,
granuloma annulare,
mycosis fungoides

Scarlet fever,
phototoxic, eruption,
GVHD,
SSSS, exfoliative
dermatitis, Kawasaki
disease,
paraneoplastic
pemphigus

Scarlet fever, phototoxic

eruption, GVHD, SSSS,
exfoliative dermatitis

Erythema
Multiforme

Stevens
Johnson
Syndrome

Toxic
Epidermal
Necrolysis

Course and
Prognosis

Lesions last 2 wks

and heal without
complications

46 wks course
5% mortality

30% mortality
due to fluid
loss, regrowth
of epidermis by
3 wks,
secondary
infection

Management

Symptomatic
treatment (oral
antihistamines, oral
antacids)
Corticosteroids in
severely ill
(controversial)
Prophylactic oral
acyclovir for 61 2
months for
HSVassociated EM
with frequent

Prolonged
hospitalization
Withdraw suspect
drug
Intravenous
fluids
Infection
prophylaxis
Consider IVIG

As for
StevensJohnso
n syndrome
Admit to burn
unit
Debride frankly
necrotic tissue
Consider IVIG

Thesyndromeis induced by epidermolytic exotoxin released byS.

aureusand cause detachment within the epidermal layer and peeling of
skin
affects infants, young children and individuals with a depressedimmune
systemor renal insufficiency

Sign and Symptoms:

Blisters
Fever
Large areas of skin peel or fall away
Painful skin
Redness of the skin, which spreads to cover most of the body
Skin slips off with gentle pressure, leaving wet red areas (Nikolsky's sign)
Fluid loss
Tests may include: CBC, Cultures of the skin and throat, electrolyte,
Skin biopsy (in rare cases)
Hospitalization , rehydration & IV antibiotics are mainstay of treatment,
Healing begins about 10 days after treatment.

It is an inflamation of the fat cells under the skin

(panniculitis)characterized by round, red, tender, poorly demarcated
nodules
Sites: asymmetrically arranged on extensor lower legs, knees, arms
Associated with arthralgia, fever, malaise
40% are idiopathic, drugs: sulfonamides, oral contraceptives,
analgesics, retinoic acid
Infections: GAS, TB, histoplasmosis, Yersinia, hepatitis C
mycoplasma
Inflammation: sarcoidosis, Crohn's > UC
Malignancy: acute leukemia, Hodgkin's lymphoma
Chest x-ray (to rule out chest infection and sarcoidosis) and
throat culture, antistreptolysin (ASO) titre, (PPD) skin test
EN is self limiting and usually resolves itself within 36 weeks.
Bed rest, compressive bandages, wet dressings, NSAIDs and treat
underlying cause

The rash and mucous membrane lesions

shown in the photograph
develop in an infant 5 days into the course
of an upper respiratory infection with otitis
media, being treated with amoxicillin. The
childs condition is likely
a. Urticaria
b. Rubeola
c. Stevens-Johnson syndrome
d. Kawasaki disease
e. Scarlet fever

The answer is c. The combination of erythema

multiforme and vesicular, ulcerated lesions of the
mucous membranes of the eyes, mouth, anus, and
urethra defines the Stevens-Johnson syndrome
(erythema multiforme major). Fever is common, and
even pulmonary involvement occasionally is noted;
the mortality rate can approach 10%. Common
complications include corneal ulceration;
dehydration due to severe stomatitis, and,
subsequently, poor fluid intake; and urinary
retention caused by dysuria. Among the known
causes of the Stevens-Johnson syndrome are allergy
to various drugs (including phenytoin, barbiturates,
sulfonamides, and penicillin) and infection with a
variety of organisms including Mycoplasma
pneumoniae or herpes type 1

The previously healthy 4-year-old child pictured presents

to the emergency room with a 2-day history of a brightly
erythematous rash and temperature of 40C (104F).
The exquisitely tender, generalized rash is worse in the
flexural and perioral areas. The child is admitted and
over the next day develops crusting and fissuring around
the eyes, mouth, and nose. The desquamation of skin
shown occurs with gentle traction. This child most likely
has

a. Epidermolysis bullosa
b. Staphylococcal scalded skin syndrome
c. Erythema multiforme
d. Drug eruption
e. Scarlet fever

The answer is b. Also known as Ritter disease,

staphylococcal scalded skin disease is seen most
commonly in children less than 5 years of age. The rash
is preceded by fever, irritability, erythema, and
extraordinary tenderness of the skin. Circumoral
erythema; crusting of the eyes, mouth, and nose; and
blisters on the skin can develop. Intraoral mucosal
surfaces are not affected. Peeling of the epidermis in
response to mild shearing forces (Nikolsky sign) leaves
the patient susceptible to problems similar to those of a
burn injury, including infection and fluid and electrolyte
imbalance. Cultures of the bullae are negative, but the
source site is often positive. Treatment includes
antibiotics (to cover resistant Staphylococcus aureus)
and localized skin care. Recovery without scarring can
be expected.

A 14-year-old girl awakens with a mild sore throat,

low-grade fever,and a diffuse maculopapular rash.
During the next 24 h, she develops tender swelling
of her wrists and redness of her eyes. In addition,
her physician notes mild tenderness and marked
swelling of her posterior cervical and occipital
lymph nodes. Four days after the onset of her
illness, the rash has vanished. The most likely
diagnosis of this girls condition is
a. Rubella
b. Rubeola
c. Roseola
d. Erythema infectiosum
e. Erythema multiforme

The answer is a. Symptoms of rubella, usually a mild

disease, include a diffuse maculopapular rash that lasts for 3
days, marked enlargement of the posterior cervical and
occipital lymph nodes, low-grade fever, mild sore throat, and,
occasionally, conjunctivitis, arthralgia, or arthritis. Persons with
rubeola develop a severe cough, coryza, photophobia,
conjunctivitis, and a high fever that reaches its peak at the
height of the generalized macular rash, which typically lasts for
5 days. Koplik`s spots on the buccal mucosa are diagnostic.
Roseola is a viral exanthem of infants, in which the high fever
abruptly abates as a rash appears. Erythema infectiosum (fifth
disease) begins with bright erythema on the cheeks (slapped
cheek sign), followed by a red maculopapular rash on the
trunk and extremities, which fades centrally at first. Erythema
multiforme is a poorly understood syndrome consisting of skin
lesions and involvement of mucous membranes. A number of
infectious agents and drugs have been associated with this
syndrome.

THANK

YOU

5 and
2 is correct ans.

ANWER IS

RSV