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Dermatological emergencies: a prospective

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Dermatological emergencies Contributors

ORIGINAL ARTICLE

Dermatological emergencies: a prospective study in a tertiary

care hospital, Gujarat, India
Patil Priyanka C.1, Mistry Amit S.2, Thakkar Sejal H.3*, Umrigar Dipak D.4, Patel
Rasesh D.5, Rathwa Mukesh V.6
1
MD, Resident, 4MD, Professor & Head, 5MD, Senior Resident, Department of Skin & VD, New Civil Hospital &
Government Medical College, Surat, Gujarat, India
2
MD, Associate Professor, Department of Skin & VD, AMC MET Medical College & LG Hospital, Maninagar,
Ahmedabad
3
MD, Associate Professor, Department of Skin & VD, GMERS Medical College & General Hospital, Gotri, Vadodara,
Gujarat, India
6
MD, Assistant Professor, Department of Skin & VD, SSG Hospital & Government College, Baroda, Gujarat, India

ABSTRACT
BACKGROUND: There are many emergencies that require rapid dermatologic consultation for early diagnosis
and appropriate therapy to prevent high mortality or severe disabling complications. Dermatologist plays a
crucial role in such conditions. The study was carried out to evaluate the clinical pattern of various
dermatological emergencies and to identify true and pseudo dermatological emergencies. MATERIALS AND
METHOD: A prospective observational study was carried out in dermatology department of a tertiary care
hospital. Patients of more than 12 years of age presenting with dermatological emergencies were studied with
their clinical and investigative profile and managed accordingly. Data was analyzed using Epi-info software
version 7. RESULTS: Data regarding demographic details, clinical features, treatment and complications was
recorded. 100 patients were included out of which 59 were males and 41 females. The highest incidence (75%)
was noted in 21-50 years of age group. 68% cases had true emergency while 32% had pseudo dermatological
emergency. 59% of cases showed mucosal involvement. 19 different conditions were observed with commonest
being acute urticaria (29%), erythroderma (13%), lepra reactions (13%), pemphigus vulgaris with/without
septicemia (9%) and SJS-TEN (13%). 41% cases were of drug reaction. The drugs involved were non- steroidal
anti-inflammatory drugs, amoxicillin, ciprofloxacin, antiretroviral drugs and sulphonamides. Mortality was seen
in 4% of cases which included pemphigus vulgaris with septicemia, anaphylaxis after blood transfusion and
purpura fulminans due to meningococcemia. CONCLUSIONS: Diagnosis and management of common
dermatological emergency conditions should be stressed during the training of physicians in emergency
medicine.

Keywords: Dermatological emergencies, Mortality, Pseudo emergency

INTRODUCTION forms a crucial link in identifying these

Many physicians and patients do not conditions, stabilising the patient and
believe that dermatology involves life- choosing the vital interventions for the
threatening diseases. However, there are management of patient.
many emergencies that require rapid Any dermatological disease or other
dermatologic consultation for early systemic disease which involves extensive
diagnosis and appropriate therapy to area of the skin and/or mucous membrane,
prevent high mortality or severe disabling which endangers the life of a patient,
complications. It has been reported that makes the patient apprehensive to consult
approximately 5% to 8% of all emergency dermatologist urgently, and may
department (ED) visits are due to skin necessitate rapid diagnosis, hospitalization
complaints.(1) Hence a dermatologist and intervention should be identified as a
dermatological emergencies. Certain
*Corresponding Author conditions present with acute onset of skin
Dr. Sejal Thakkar lesions with/ without systemic symptoms
201, Wings Ville makes patient apprehensive and to consult
41, Arunoday Society dermatologist urgently. These conditions
Alkapuri, Vadodara-398007 are not true emergencies but because of the
Phone: 91-9824097310 acute fearing presentation of the sign and
E-mail – [email protected] symptoms, many patients are seen at
90 Int J Res Med. 2014; 3(4);90-95 e ISSN:2320-2742 p ISSN: 2320-2734
Dermatological emergencies Contributors
emergency department at any time. These done mainly on clinical basis. SCORTEN
conditions are labelled as pseudo (severity-of-illness score for Toxic
dermatological emergencies. Epidermal Necrolysis (TEN)) in case of
Since there are very few studies, especially patients with Stevens Johnson syndrome
from India (2) attempted to characterize and Toxic epidermal necrolysis (SJS-TEN)
dermatological emergencies, this study was noted in the first 24 Hours of hospital
was conducted to know various admission. Routine investigations were
presentations of dermatological carried out in all and specific
emergencies and evaluate mortality in such investigations were done as and when
cases. The purpose of the study was to required. Informed written consent was
provide a useful information guide for taken from all patients or patient’s
identifying common and life threatening relatives before including them into the
skin diseases which need to be recognized study group. Clinical photographs were
at the earliest at the primary care level so taken as and when needed. Patients were
that patients can receive prompt and treated accordingly. All patients were
accurate initial treatment with timely followed up as per the requirement.
referrals. So, the study was carried out to Data was entered into the computer and
evaluate the clinical pattern of various skin analysed by using Epi-info software
diseases presenting as dermatological version
emergencies as well as to identify true and RESULTS
pseudo dermatological emergencies. Table: 1 Pseudo Dermatological
MATERIALS AND METHOD emergencies
A prospective observational study was Diagnosis No. of
carried out over a period of one year from cases (%)
April 2011 to March 2012 in department Acne fulminans 1 (3.1)
of dermatology of a tertiary care teaching Acute generalised pustular psoriasis 2 (6.3)
Balanoposthitis with phimosis 1 (3.1)
hospital in Gujarat, India. Institutional Chancroid with paraphimosis 1 (3.1)
ethical clearance was obtained before the Extensive maculopapular rash 6 (18.8)
start of the study. Pre designed and Dapsone hypesensitivity syndrome 1 (3.1)
pretested proforma was filled after taking Henoch schonlein purpura 2 (6.3)
informed consent. Privacy and Herpes zoster 3 (9.4)
confidentiality was maintained. Lepra reaction 13(40.6)
Phagedenic chancroid 2 (6.3)
All patients of more than 12 years of age
Total 32 (100)
attending emergency department or indoor
Of the 100 patients studied, 59 (59%) were
patients having skin lesion/mucosal lesion
males and 41(41%) females. Age ranged
with/without systemic complaints,
from 12-70 years. Maximum cases (75%)
requiring urgent interventions,
were in the age group of 21-50 years with
investigation or hospitalization were
decreasing frequency towards the extremes
included. Patients having factitious
of age. 83% were pertaining to
complaints or patient visiting emergency
dermatology cases while 13% and 4%
department with casual skin lesions
were of leprosy and Sexually Transmitted
/mucosal lesion with / without systemic
Diseases (STDs) respectively. 68% cases
complaints were excluded from the study.
were of true dermatological emergencies
A detailed history regarding cutaneous as while 32% were of pseudo dermatological
well as systemic manifestations of all the emergencies. (Table 1) 59% of
patients was taken and recorded as per a dermatological emergency cases were
structured questionnaire. In case of a having mucosal involvement either single
suspected drug reaction, name of the drug, or multiple (oral, eye, genital, nasal, and
incubation period and past history of anal). Oral cavity (78%) and eye (77%)
similar episode were noted. Clinical involvement was more common than the
examination was done with particular genital lesions (32%). In multiple mucosal
emphasis on type and extent of skin and involvements, combination of eye/ oral
mucous membrane lesions. Diagnosis was and eye/ oral/genital were more common.
91 Int J Res Med. 2014; 3(4);90-95 e ISSN:2320-2742 p ISSN: 2320-2734
Dermatological emergencies Contributors
Total 19 different conditions were septicemia (9%). (Figure 4, 5)
observed during the study. (Figure 1) The Out of 29 (29%) cases of acute urticaria
commonest presenting conditions were with or without angioedema, 20 (68.96%)
acute urticaria with or without angioedema were of drug induced and 6 (20.68%) of
(29%) (Figure 2) followed by acute food allergy. Most commonly implicated
erythroderma (13%), SJS-TEN (13%), food was fish (four out of six patients).
(Figure 3) lepra reactions (13%), and Other cases were of insect bite e.g. bee and
pemphigus vulgaris with/without idiopathic where no cause was identified.
Table 2 Drugs causing dermatological emergencies
Urticaria and SJS 9 (21.95%) Extensive Erythroderma Dapsone
angioedema SJS/TEN 1 (2.43%) maculopapular 3(7.32%) hypersensitivity
20 (48.8%) TEN 3 (7.32%) rash syndrome
Drug % Drugs % 4 (9.75%) 1(2.43%)
Ciprofloxacin 19 Nevirapine 53.8 Co-trimoxazole Phenytoin Dapsone
NSAIDS 38.1 Sulphonamide 15.4 Amoxicillin Deriphylline
Metronidazole 4.8 NSAIDS 23.1 Paracetamol Thiazide
Aminoglycosides 4.8 Amoxicillin 7.7
Amoxicillin 19
Chloroquine 9.5
Co-trimoxazole 4.8
Out of 13 cases of acute erythroderma, drugs causing SJS and TEN were
psoriasis (30.8%) and pemphigus antiretroviral drugs (Nevirapine) in seven
foliaceous (30.8%) were more common cases followed by Non-steroidal anti-
than drug induced (23%) and idiopathic inflammatory drugs and sulphonamides.
cases (15.40%). (Table 2)
Out of 13 cases of SJS-TEN, nine cases Mortality was seen in 4% of cases. Two
were of SJS, three of TEN and one was of were female patients having pemphigus
SJS-TEN overlap. Seven cases were HIV vulgaris with septicemia, one case was a
positive, on antiretroviral therapy. CD4 female with anaphylaxis after blood
cell count was variable ranging from 55- transfusion and the other was male patient
440 cells/mm3 in these cases. So, there with purpura fulminans due to
was no significant correlation between meningococcemia.
CD4 cell count and the drug reaction. DISCUSSION
Average SCORTEN was 2.3 in patients of Certain dermatological conditions can be
TEN and 0. 78 in SJS and SJS-TEN sudden in their onset and distressing to the
overlap syndrome. patient. The appearance of a rash or any
Amongst 13 patients with leprosy, unfamiliar symptom on one’s skin is often
frequency of Type 2 lepra reaction enough reason for one to seek medical
(76.9%) was much greater than Type 1 attention.
lepra reaction (23.1%). The mean age in this study was 36 years
The conditions presenting with Sexually which correlates with the studies of M.L.
Transmitted Diseases (STDs) were Martínez-Martínez et al and Gonzalez
phagedenic chancroid (50%), Ruiz et al. (3, 4) Higher frequency in this
balanoposthitis with phimosis (25%) and age group shows concern for their
chancroid with paraphimosis (25%). appearance. Slight lower preponderance in
Out of 100 cases, 41% cases were of drug females (41%) is observed in the study.
reaction. Most common drug reaction This can be considered as an indicator of
presenting as an emergency was acute the health seeking behaviour in females, as
urticaria with or without angioedema they tend to rely more on self- medication
(48.8%), SJS-TEN (31.7%) and extensive with household therapies and avoid
maculopapular rash (9.8%). Non- steroidal visiting the physician unless they have
anti-inflammatory drugs were the aggravation of the disease.
commonest drugs (38.1%) causing acute The incidence of pseudo-dermatological
urticarial reactions, followed by emergencies (32%) is lower than that seen
amoxicillin and ciprofloxacin. Common in the studies done by Gupta et al (79%)
92 Int J Res Med. 2014; 3(4);90-95 e ISSN:2320-2742 p ISSN: 2320-2734
Dermatological emergencies Contributors
and Mirkamali A et al (51% in 2010 and 30.8% in pemphigus foliaceous. These
57 % in 2000). (2, 5) They were found to patients had history of skin lesions specific
be less common in present study as the for the disease, but because of lack of
out- patient department working hours (6 treatment or inappropriate treatment it
hours/day and 6 days/Week) in our rapidly converted to erythroderma. Other
hospital are more. Also, patients can walk common causes were drug reaction
in freely without requiring any prior culminating into erythroderma, and rest
appointments. Majority of the patients in was idiopathic.
the study region were industrial workers SJS-TEN was observed in 13% of cases
who could work in shift hour duties (with comparable to the study done by
option of adjusting duty hours), they could Alexander et al (22%).(8) Higher
visit the hospital during routine hours frequency of SJS-TEN with nevirapine in
which might be the reason for decreased HIV positive cases in the present might be
frequency of pseudo-dermatological because of high prevalence of HIV in the
emergencies. city and nearby areas. Those HIV positive
Mainly leprosy, STDs and Herpes zoster patients have inherently high risk of SCAR
(21%) were found with infective causes (Severe cutaneous drug reaction) e.g. SJS-
while urticaria and drug reactions were the TEN explaining high frequency (13%) in
major contributory factors in non infective present study, while in Wang E et al series
causes. frequency of SJS – TEN was only
As acute urticaria with or without 0.60%.(6) According to previous data, risk
angioedema is very common in the of nevirapine induced hepatotoxicity and
population, and that fact is also strongly other side effects are increased if the CD4
supported by the findings of the present cell count are >250/mm3 in females and
study accounting for the 29% cases >400/mm3 in males. (9) Although number
compared to Wang E et al series reporting of patients was very few in the study, an
11.40%.(6) Even it was most common in attempt was made to correlate the CD4 cell
study of 68.1% done by Kim JY et al. (7) count and occurrence of SJS-TEN. Data
Acute urticaria has varied aetiology e.g. showed that the CD4 cell counts ranges
drug reaction, food allergy, insect bite, from 55 to 440 in patients with SJS-TEN
infection, blood transfusion and rapid and no significant correlation was found.
onset of wheals with itching, fast Ours is one of the cities having high
progression, oedema of eyes and lips, incidence and prevalence of HIV which
many a times difficulty in breathing, provides free of cost Anti retroviral
necessitate the patient to report to doctor, therapy (ART) to needy patients.
and this may be the reason for high SCORTEN was found 0.78 to 2.3 with
frequency of reporting of acute urticaria statistical mortality risk of 3.2 to 35.8% in
with or without angioedema in the of SJS & SJS-TEN overlap syndrome. (10)
emergency department. In acute urticaria No mortality was reported in this study
patients, drug reaction cases were most with SJS & SJS-TEN overlap syndrome.
common (68.96%) followed by food Frequency of drug reaction as
allergy (20.68%). This high frequency of dermatological emergency cases was seen
drug reaction may be due to easily in 41% in present study, while in Wang E
available over the counter drugs and their et al series, it was 10.29%. (6) Common
inadvertent use. Urticaria due to food is drug reactions were acute urticaria with or
more of chronic type, but acute without angioedema (48.8%), SJS-TEN
presentations were seen in six cases in this (31.7%), extensive maculopapular rash
study. Fish was the main culprit in four of (9.8%). Other less common drug reactions
them. were three cases of acute erythroderma and
Acute erythroderma was another common one of Dapsone hyper sensitivity
dermatological emergency which syndrome. As stated above high frequency
accounted for 13% of total cases. Out of of SJS-TEN in present study may be
total 13 cases, 30.8% cases were of because of high prevalence of HIV in the
psoriatic origin with same frequency of city and nearby areas.
93 Int J Res Med. 2014; 3(4);90-95 e ISSN:2320-2742 p ISSN: 2320-2734
Dermatological emergencies Contributors
High frequency of lepra reactions (13%) having pemphigus vulgaris with
may be justified by the fact that there is a septicemia, one each case was of a female
high prevalence of leprosy in the city and with anaphylaxis after blood transfusion
areas periphery to the city. Ours is a and a male of purpura fulminans due to
rapidly developing city with large textile meningococcemia. Pemphigus vulgaris
market and lots of other industries, there is was noted to be the commonest cause of
a large migrant population from the states mortality. It is consisted with the study
with high leprosy prevalence. Most of the conducted by Nair et al. (11) Frequency of
leprosy patients reported in the leprosy death was higher in females (75%). As
clinic are migrant population. Like ART in previously said, this might be due the
case of AIDS, anti leprosy treatment tendency of the females to visit the
(ALT) is being provided free of cost to the hospital only in advanced stage of the
needed leprosy patients by many disease. It was reported that nursing care
government centres, there are more was one of most important factors in the
number of leprosy patients attending this survival of patients in cases of SJS-TEN
hospital. As in Type - 2 lepra reaction and pemphigus vulgaris with septicemia
systemic signs and symptoms are more patients in addition to the fluid
severe than in Type – 1 lepra reaction, management and antibiotic coverage.
Type – 2 reaction is more frequently Conclusion: In most of the hospitals, the
reported in the emergency department as in patient presenting with a dermatological
the present study (76.9%). condition to the emergency department
Pemphigus vulgaris was seen in nine cases (ED) is evaluated by the emergency
(9%) in the present study while in Wang E resident physician, and not by the
et al series frequency of Immunobullous dermatologist. This means that in a
disease was 0.80%. Patients with considerable percentage of cases the
Pemphigus Vulgaris with septicemia are patient does not receive a diagnosis and a
mostly from the lower socioeconomic specific treatment and is subsequently
class, illiterate and belonging to the rural referred for dermatology consultation. So,
areas. Most patient present late (1-2 diagnosis and management of common
months) after the onset of disease, and do dermatological emergency conditions
not take any treatment during this period, should be stressed during the training of
predisposing themselves towards physicians in emergency medicine.
septicemia. Patient presented with high Limitations: As the study was carried out
grade fever, wide spread flaccid bulla, only at only one centre and many patients
erosions and crusting with significant taking treatment from other city hospitals
mucosal involvement and typical mousy were not included in the study, the true
odour. incidence of dermatological emergencies is
Emergency conditions associated with difficult to determine. This study did not
STDs, reported in the present study were include consultations performed for the
two cases of phagedenic chancroid, and paediatric emergencies. So, our findings
one each of chancroid with phimosis and do not apply to the paediatric population.
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