Skin Infection and Conditions Emergencies

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Skin Infection and Conditions Emergencies

Postby patoco » Thu Jul 06, 2006 8:17 am

Skin Infection Emergencies

Lymphedema People


We have many pages of information relating to skin infections because of the serious potential that have for those of us with lymphedema. We need to be able to early recognize an infection, what to look for and importantly what to do.

Ignored or untreated any skin infection can rapidly become systemic and/or life threatening.


Dermatologic Emergencies


Most skin conditions are not emergencies, but the condition of a person’s skin can be an indication of their overall health. For example, severely dry skin can be indicative of internal diseases such as thyroid disease. Severely itchy skin can be associated with liver disease, thyroid disease, kidney disease, and rarely, internal cancers. In addition, hair loss can be associated with other medical conditions such as severe stress, thyroid disease, anemia, drug reactions, or poor nutrition. Any persistent skin condition should be evaluated by a dermatologist.

The following is an example of a true dermatologic emergency:

Case Study

It was the morning of January 1, 1996 when my beeper suddenly went off. It was the emergency room. I was being called for a stat dermatology consult. While most dermatology consults are not considered emergencies, this one certainly was.

By the time I had reached the emergency room, the patient, a 35-year-old woman who had been on medication for arthritis, had begun to develop severe swelling around her eyes, mouth, and nose. In addition, a small blister had developed on her left thumb. A skin biopsy of the blister was performed immediately, and the pathologist on call was summoned to the emergency room. She and I evaluated the biopsy and my deepest fears were realized. This patient had developed a skin condition called toxic epidermal necrolysis (also known as TEN). This condition is the most serious type of drug reaction.

The patient was placed on sterile sheets and hooked up to a cardiac monitor. Her blood was drawn every two hours in order to make sure that she was not becoming dehydrated. A burn unit in Manhattan was notified and the patient was prepared for transfer. By the time she was ready to leave for the burn unit, large blisters had developed on her back, chest, face, and hands. This had occurred within a matter of hours.

The next day, I had contacted the burn unit in order to find out how my patient was doing. I was told that she had lost approximately 87 percent of her skin and that she was expected to remain in the unit for several months. As it turned out, she stayed in the burn unit for total of five months. Happily, however, she has made a full recovery with no long-lasting effects.

Physicians like to joke that there is no such thing as a dermatologic emergency. For the most part, they are correct. However, as you can see by the above example, dermatologic emergencies do in fact exist.

Blistering Skin Disorders

Although most blistering skin disorders (such as poison ivy) are not life threatening, some blistering skin diseases, like the above example, represent true dermatologic emergencies.


Sunburn can constitute a dermatologic emergency. Sunburn usually presents as red, inflamed skin. Typically, the redness begins approximately three to four hours after exposure to the sun and can continue to intensify for up to twelve hours after exposure. Most cases of sunburn can be managed at home with a combination of cool compresses and prescription medications, such as topical steroid creams. When sunburn is very severe, it leads to the formation of large blisters. In this case, treatment at a burn unit may be necessary until the skin completely heals. This treatment may involve sterile dressings, intravenous fluid replacement, and occasionally systemic antibiotics (antibiotic medications that travel throughout the body, usually administered in pill or intravenous form).

Pemphigus vulgaris

Pemphigus vulgaris is another example of a blistering disease that requires immediate medical attention. Pemphigus tends to occur in younger patients, people in their 20s, 30s, and 40s. This condition is not the result of a drug allergy. It usually, but not always, starts as a severe inflammation involving the mouth. As the disease progresses, blisters begin to develop all over the body. It must be diagnosed immediately and treated with high-dose oral steroids such as prednisone. Otherwise, the disease is often fatal.

While some blistering diseases may present with the most serious outcomes, they are not the only skin conditions that may represent dermatologic emergencies. I would like to briefly discuss other skin conditions that can be quite serious.

Skin Infections

Most skin infections are superficial and not life-threatening. They are easily treated with topical or oral antibiotics.


However, a condition known as cellulitis can become very serious. Cellulitis is a deep skin infection caused by bacteria, and is most common in people with immunosuppressive diseases such as diabetes. When a person develops cellulitis, the skin becomes red, inflamed, and very warm to the touch. These topical symptoms are sometimes accompanied by generalized (systemic) symptoms such as fever and chills.

Treatment: It is imperative that cellulitis be treated with systemic antibiotics. Oral antibiotics will often be enough. If oral antibiotics are not effective, intravenous antibiotics, administered in the hospital, must be used. If cellulitis goes untreated, a severe life-threatening infection may occur, including something called necrotizing faciitis.

Necrotizing fasciitis

This is a very rare condition that can develop in a matter of hours. A few years ago, this condition made headlines as the so-called flesh-eating virus. However, this infection is not caused by a virus. It is a bacterial infection. I have seen two cases of necrotizing fasciitis in my career. In both instances, the patients presented with a severe cellulitis that had rapidly progressed to purple-colored skin.
Treatment: In both cases, the patients were treated with intravenous antibiotics and surgical removal of the infected tissue had to be performed. If this type of infection does not receive immediate care, the chances of the patient dying are very high.


Hives (also known as urticaria) is a skin condition that appears as red, very itchy, bumps. These bumps often disappear within 24 hours only to be replaced by new ones. Hives, like most skin conditions, can be made worse if accompanied by emotional stress. The most common cause of hives is food allergy. However, hives can also be caused by an allergy to medication or by other allergenic factors. It is estimated that one in five people will have hives at some point in their lives.

In addition, hives that persist can sometimes be an indication of other medical problems such as liver disease, thyroid disease, or connective tissue diseases such as lupus. If you develop hives that do not go away, you should be evaluated for other medical problems.

Hives, for the most part, are not life-threatening. However, if swelling develops around the mouth, the condition may also begin to involve the throat. This, in turn, may lead to serious problems with breathing. When this happens, you must go immediately to an emergency room for treatment.

Treatment of hives

Hives should be treated with systemic medications. Initially, oral antihistamines such as Benadryl, can be used. If this is not effective, oral prednisone (a steroid medication) may be required. In very severe cases, where breathing may be compromised, injected, intra-muscular epinephrine (also called adrenaline, a potent steroid medication that increases the heart rate, constricts blood vessels, and opens up airways) may be needed. This, of course, must be administered in the emergency room.

Drug Reactions

Drug reactions usually appear as rashes involving all or part of the body. While most drug reactions occur within two weeks of starting the drug, it is important to remember that any medication can cause a reaction in anyone, at any time, while they are taking a drug. Most drug rashes are benign (not harmful), do not represent a serious condition, and go away when the offending medication is stopped.

Stevens-Johnson syndrome: However, if you are allergic to a medication, and you continue to take that medication, a serious drug reaction called Stevens-Johnson syndrome may develop. In this syndrome, in addition to the skin rash, the lining of the nose, mouth, and eyelids become inflamed. This condition can be life-threatening and the offending drug must be stopped immediately. If the drug is not stopped, toxic epidermal necrolysis (TEN), the condition described previously, may result.


While most skin lesions are not emergencies, as we discussed above, there are a few conditions that require rapid medical attention. If you have a skin lesion that is rapidly changing or is accompanied by systemic symptoms such as fever or chills, you should contact your physician. He or she will either be able to address your problem directly or refer you to an appropriate expert. ... encies.asp


New Treatments for Impetigo and Skin Infections


This talk will be on skin and soft tissue infections. The way I will break this down is sort of anatomically - going through infections spreading from outer layers of the skin to deeper layers of the skin, subcutaneous fat and tissue and then fascia and muscle. Along the way, we will talk about some specific clinical situations as well, including diabetic foot infections.

We'll start with the outer layers. Impetigo, which is a very common superficial skin infection, is almost always caused by either group A beta hemolytic streptococci or Strep pyogenes or Staph aureus and may be a mixture of those two organisms. It is more common in children and it is more common in warmer weather, although it can occur year-round, and it certainly can occur in adults. The major mimic and the major differential diagnostic piece here is differentiating it from cutaneous herpes infection.

Most commonly, the organisms come from a colonized pharynx. The clinical scenario is that someone presents with a pharyngitis, either symptomatic or asymptomatic, that won't bring someone to medical attention but that you can elicit historically when you are seeing them with the rash and you suspect impetigo. But most likely, that is where the organism comes from; it is someone who has it in their throat and then spreads it to their skin. The reason it causes an infection is because of micro breaks in the skin.

Impetigo is incredibly contagious. It spreads very rapidly from person to person. If you are dealing with children in day care centers where one kid has it, then a lot of the rest of the kids in the group are going to have it, but it can also spread in households.

The treatment of this infection is usually now a combination of things. With the availability of topical mupirocin, or Bactroban, this is a very effective topical agent against both group A strep and staphylococci. So this is a very useful adjunct in the treatment and sometimes can be used as the only treatment for impetigo. Most people, however, combine topical agents with oral agents. Most group A strep - the vast majority of group A strep, remain very sensitive.

Erysipelas is also a streptococcal infection and it is an infection a little bit deeper down; it is an infection of the superficial dermis due to streptococci, almost always group A strep. The more unusual ones are due to non-group A beta hemolytic streptococci. You can see an erysipelas-like disease due to group B strep, group C strep, occasionally even some of the other beta hemolytic streptococci, such as group G strep.

These people, in contrast to people with impetigo, where constitutional symptoms are either mild or absent, commonly have constitutional symptoms. Those symptoms can be severe - people can be very sick with erysipelas. They can have fever, shaking chills and pain in the region. This is the occasion where sometimes when you think about treating.

In terms of anatomically, you usually see this on the extremities, but it may occur on the face in about ten percent of cases. I've seen this a few times, including in some colleagues who I've worked with, where they are on rounds in the afternoon and have a little bit of irritation on their nose; they scratch their nose and then during the course of afternoon rounds.

When you see someone with a lower extremity cellulitis, erysipelas or any kind of skin infection, particularly if it is recurrent, look for athlete's foot, because if you see it, you can treat that and decrease their risk of a recurrent skin infection. As I mentioned, this is true in wounds as well. Erysipelas, as I said before, is usually a clinical diagnosis. Therapy depends on how sick somebody is. There are not clear guidelines for this; this is a clinical judgment call.

The next layer down is cellulitis. Cellulitis involves all layers of the skin to the subcutaneous tissue. It is also a clinical diagnosis. It is a spreading, warm, flat, red area. The systemic symptoms that are associated with cellulitis are variable and can range from none to severe. This really not only depends on the bacteria that is causing it, but also the underlying host, how long the infection has been going on and a lot of other things.

Let's talk about a subset of this, a diabetic foot infection. So now we are extending cellulitis potentially down further when we talk about this. The risks for disease after local trauma, which may be minor, for example, rubbing against a new shoe, which allows minor skin breakdown but can allow organisms to get in, and because there is an abnormal blood supply due to the peripheral vascular disease which is very common in diabetics, those organisms are allowed to set up shop and cause infection. Diabetics are at increased risk for trauma because neuropathy is very common, so they may not feel the fact that their shoe is rubbing against their foot and that is what puts them at risk for the local trauma. Prevention here is extremely important.

Necrotizing fasciitis is an acute clinical presentation. These people are systemically ill. The hallmark of this illness is extreme pain. This is pain out of proportion to clinical appearance. Just like ischemic colitis, where you think about pain out of proportion to exam, here when someone complains of extreme pain in their extremity and they have a little cellulitis or a little bit of redness on their leg but their pain is really out of proportion to that, one of the things you would think of is whether the infection may be deeper than it looks. Another thing might be what is going on with the vascular system and is there vascular insufficiency.

I would like to say a few words about bite wounds - animal and then human bites. Fifty percent of U.S. citizens will have at least one animal bite throughout their lifetime; this is a very common occurrence. It accounts for about one percent of all emergency room visits and anatomically occurs on the hands and face most often. The bacterial flora depends on what the animal is. You will need to know specific animals and what the organisms are.

When do you give prophylaxis for animal bites? You usually do it for wounds on the hands, near the joints, on the genitals or with bad crush injury. You don't need it for bites of greater than 24 hours' duration. If the bite occurred two days ago and there is no sign of infection, you don't need to do it. In general, if prophylaxis is given, it is continued for three to five days.

Now a word about human bite wounds. The mechanism of injury is usually clenched fist as part of a fight or self inflicted. Bacterial flora is human mouth flora. The unusual organism here is an oral anaerobe called Eikenella and skin flora as well. The rate of infection with human bite wounds is higher than with animals. Surgical treatment is the most important thing. Prophylactic antibiotics are usually given due to the higher rates of infection; so that is the difference between human and animal bites. Because the risk of infection is higher, you generally treat for three to five days. If the injury is on the hand, patients are hospitalized. ... ctions.htm


Related Article (PDF)

Practice Guidelines for the Diagnosis and Management of
Skin and Soft-tissue Infections.

IDSA Guidelines ... 44992Guest

or ... 37519.html
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