1-2 mm hemorrhagic lesions; can be a sign of thrombocytopenia, vasculitis, infection or trauma
3-10 mm hemorrhagic lesions, non-blanchable and may or may not be palpable; similar differential as petechiae
Younger patients with diffuse petechial lesions turning into palpable purpura. If suspected you should LP these patients, start IV Rocephin and IV decadron (although don't delay antibiotics for the LP)!!
10-20 pustule or petechial lesions with fever and migratory polyarthritis. Can be found on the palms. Treatment is IV Rocephin.
Usually secondary to DIC caused by sepsis, trauma, malignancy. Management includes treatment of the underlying etiology.
Comes in two varieties: major and minor. These are usually caused by underlying infection. The rash has multiple red, flat, elevated papillose with a target like appearance.
Major: EM has blisters within the papules, and the patient will generally be more toxic appearing. May affect mucous membranes
Similar to EM Major, but etiologies differ. SJS typically caused by drug reaction. SJS has more flat/macular lesions, start at the face/thorax, spare the palms/soles, scalp and affect the mucous membranes. There is painful blistering and sloughing of skin which affects <10% TBSA. Treatment is withdrawal of culprit and supportive care.
Toxic Epidermic Necrolysis
Same spectrum as SJS but affects > 30% TBSA. If TBSA affected is > 10% but < 30%, then it is considered SJS/TEN overlap. Treatment is supportive, and these patients should be managed in an ICU and/or burn setting.
Staphylococcal Scalded Skin Syndrome
Seen in children < 6 years, will also have diffuse erythema and possible skin sloughing as in SJS. SSS does NOT affect mucous membranes and is not triggered by a medication as is SJS. Treatment includes anti-staph antibiotics.
Auto-immune disorder affecting adults age 40-60 years old. There are multiple small, flaccid bull and will have painful oral involvement. Nikolski's sign positive. Treatment is high dose steroids (life saving).
Occurs in older individuals, > 70 years old, with large tense bull, Nikolski's sign negative. It is also treated with steroids but is less urgent and can be managed as an outpatient.
Inflammation of dermal and subcutaneous tissues. The skin is red, hot, and tender. Most common organisms are group A strep and staph aureus.
Similar to cellulitis but more superficial and is characterized by right red, sharply demarcated skin.
Deep, bacterial infection that is rapidly spreading with pain out of proportion to exam. There may be crepitus, bull and/or hemorrhagic bull. Classically there is dirty dishwater discharge. Type 1 is polymicrobial and associated with diabetes. Type 2 is group A strep or MRSA. Surgical consultation is required as is broad spectrum antibiotics.
Rocky Mountain Spotted Fever
Starts with a flu-like illness and fever; a rash with palpable petechiae affecting the palms/soles and spreads centrally. It is caused by a tick bite carrying Rickettsia rickettsia. Treatment is doxycycline.
Characterized by erythema migrants, a painless rash that starts as a macule or papule and grows to be a 5-7 cm lesions with central clearing (may have an erythematous center). First line treatment is doxycycline.
Grouped erythematous papule and vesicles affecting a dermatome and do not cross the midline. These are very painful and lead to post-herpetic neuralgia and other complications. Anti-viral therapy such as acyclovir or valcyclovir is indicated.
Herpes Zoster Opthalmicus
Eye-threatening condition, diagnosed via fluorescein staining, showing dendritic lesions of the cornea. Vesicular lesions of the nose, or Hutchison's sign, can be a warning sign.
Herpes Zoster Oticus
Ramsay Hunt Syndrome, can affect CN 7, 8 and patients may have tinnitus, vertigo and ipsilateral facial paralysis in addition to vesicular lesions.
Photos printed with permission from R2 Digital Library