Rash

(Dermatology for dummies… and ER docs)
My favorite rash story comes from a cruise ship. One of the filipino band members visited the ship’s clinic with pus dripping from sores all over his face and body. I treated him for presumed staph, and it actually seemed to help quite a bit. Unfortunately, his roommate and fellow band member appeared with a rash about a week later, and I got a look at the earlier stages of the lesions. This time I got the diagnosis right – adult chicken pox. After a third band member contracted it, we clearly had a public health situation, and a lot less music.

Since the US started vaccinating kids for varicella I haven’t seen chicken pox in years, and certainly not in adults. (We still see shingles, but that’s varicella resurrected.) In the Philippines, the vaccine is much less prevalent and apparently many adults never have chicken pox as kids.
Eventually when we landed in Halifax, their public health department was kind enough to give us (imagine that) a box of varicella vaccine, which I used for the remaining band members, and others on the ship who’d never come in contact with chicken pox or the vaccine.

Since then my life in dermatology has been far less exciting. We see an enormous number of skin problems in emergency departments, and I get quite a few skin related calls through Pre-R as well. However, the large majority of patients improve, or they seek smarter dermatologists elsewhere. No rash in years has had me racing a bicycle across a foreign city with a backpack of vaccine.

Red Flags:

• Fever
• Pus
• Red streaks
• Swollen lymph nodes
• Pain, especially if “out of proportion to exam”
• Stiff neck
• Local meningitis outbreak
• Blisters/sores, especially associated with recent new medications
• Swollen tongue
• Wheezing
• Asthmatic
• Light headed
• Recent tick bite
• Joint pain
• Taking warfarin

Happy Words

• Itch
• Chronic problem, such as eczema, psoriasis, venous stasis ulcer, rosacea
• No past hospitalizations, intubations or anaphylaxis
• “I’m allergic to dogs… and I just pet a dog.”
• “This is herpes and can I have a Valtrex prescription?”
• “This is poison oak and can I have a prednisone prescription?”
• “I’ve had chicken pox already.”

Dermatology can’t be taught in a post. However, here are a few points to consider. Broadly speaking, every med student hears the lines, “If it’s wet, dry it. If it’s dry, wet it.” Pretty good advice, as long as you don’t consider wet to mean water only. “Wet” includes topicals, and within that realm you’ll find ointments, which last longer than creams, which last longer than lotions.

The majority of derm problems we see in the ER land within the categories of allergic, bacterial, viral, fungal or infestational (not sure if that last one’s a word… but scabies, bed bugs, ticks, etc). Poison oak is a big topic here in California. Jelly fish and centipede stings are interesting on Hawaii. New Mexico… hard to say. With drier climate and higher altitude, skin cancers seemed more prevalent. Cancers, autoimmume and vascular problems find their way to ERs less frequently, being more chronic though.

Here are some more points to help you make decisions about which way to turn:

  • Fever, neck pain, blotchy lesions? Head to the ER or get a ride. Meningitis is the fear. So you get a sense for probabilities, however, since 1993 I’ve never had a patient myself with classic bacterial meningitis. Thank you vaccines. Viral meningitis is far more common.
  • Pain which comes on rapidly, associated with fever and rash, is also concerning. The phrase “pain out of proportion to exam” suggests a deeper infection, which may be life threatening. Google “necrotizing fasciitis” if you suffer from narcolepsy.
  • While itch can be exasperating, it is preferred over pain. Most causes of itch can be helped greatly with antihistamines +/- steroids. These represent the majority of our Pre-R derm-related calls.
  • One sided severe stabbing pain, followed later by rash, especially with a previous history of shingles?… Call us sooner than later for a Valtrex prescription. This isn’t like amoxicillin for ear infections and sinusitis. Early treatment of shingles or herpes with Valtrex really works. But it’s less helpful over time.
  • Is the rash associated with generalized illness or is it a local problem? If no associated tongue swelling, wheezing, light headedness, pain, then there is generally time to think. Give us a call. Very often these can be solved with phone conversation, or Skype/Facetime.

I could drone on and on, but suffice to say that dermatologists see some interesting problems. Dermatology really does lend itself to telemedicine though. So rather than take your lesions to a waiting room, give us a call. Hopefully we can help.

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