11.22 Diaper Rash
Presentation
An infant has worn a wet diaper too long, and has developed an uncomfortable rash, which may range fron simple redness to macerated and superinfected skin. Hallmarks of Candida (monilia) infection are often present, including intensely red, raw areas, satellite lesions, and white exudate.
What to do:
Instruct the parents that it is imperative that the child go "bare" and wear no diaper until the rash has healed. This may increase the laundry load, but it allows the skin to dry, avoid physical trauma, and restore its natural defenses. This is usually all that is necessary to clear up a diaper rash in 2-3 days, but . . .
To speed recovery from the frequent superinfection of Candida (present in the feces) and less-frequent superinfection with other dermatophytes, you may add topical treatment with clotrimazole (Lotrimin) or nystatin (mycostatin) cream, applied 3 or 4 times daily until the rash has been healed for 2 days.
Make sure the family has a pediatrician for further followup.
What not to do:
Do not let the parents be distracted by drying or emolient medications. Going bare is the basis of treatment.
Do not recommend talcum powder or "talcum free" powders for use when diapers are changed. They add little in terms of medication or absorbency, and are occasionally aspirated by infants as their diapers are being changed.
Discussion
Superinfection with Candida is common enough to treat presumptively in every case of diaper rash severe enough to be brought to the ED.
Saturday 10 August 2013
Impetigo
11.21 Impetigo
Presentation
Parents will usually bring their children in because they are developing unsightly skin lesions, which may be pruritic and are found most often on the face or other exposed areas. Streptococcal lesions consist of irregular or somewhat circular, red, oozing erosions, often covered with a yellow- brown crust. These may be surrounded by smaller erythematous macular or vesiculopustular areas. Staphylococcal lesions present as bullae which are quickly replaced by a thin shiny crust over an erythematous base.
What to do:
Prescribe mupiricin 2% ointment (Bactroban) to the rash tid for 3-5 days. Have parents soften and cleanse crusts with warm soapy compresses before applying the antibiotic ointment.
For severe or resistant cases, add a 10 day course of erythromycin or penicillin VK (250mg qid), or one intramuscular injection of benzathine penicillin (600,000 units im for children 6 years and younger, 1.2 million units im for children over 7 years.) For suspected staphylococcal infections use dicloxacillin (250mg qid) in place of penicillin (or prescribe erythromycin or cefadroxil).
What not to do:
Do not routinely culture these lesions. This is only indicated for unusual lesions or lesions that fail to respond to routine therapy.
Discussion
Impetigo is usually self-limiting and it is believed that antibiotic treatment does not alter the subsequent incidence of secondary glomerulonephritis. Impetigo is very contagious among infants and young children and may be associated with poor hygiene or predisposing skin eruptions such as chicken pox, scabies, and atopic and contact dermatitis.
Presentation
Parents will usually bring their children in because they are developing unsightly skin lesions, which may be pruritic and are found most often on the face or other exposed areas. Streptococcal lesions consist of irregular or somewhat circular, red, oozing erosions, often covered with a yellow- brown crust. These may be surrounded by smaller erythematous macular or vesiculopustular areas. Staphylococcal lesions present as bullae which are quickly replaced by a thin shiny crust over an erythematous base.
What to do:
Prescribe mupiricin 2% ointment (Bactroban) to the rash tid for 3-5 days. Have parents soften and cleanse crusts with warm soapy compresses before applying the antibiotic ointment.
For severe or resistant cases, add a 10 day course of erythromycin or penicillin VK (250mg qid), or one intramuscular injection of benzathine penicillin (600,000 units im for children 6 years and younger, 1.2 million units im for children over 7 years.) For suspected staphylococcal infections use dicloxacillin (250mg qid) in place of penicillin (or prescribe erythromycin or cefadroxil).
What not to do:
Do not routinely culture these lesions. This is only indicated for unusual lesions or lesions that fail to respond to routine therapy.
Discussion
Impetigo is usually self-limiting and it is believed that antibiotic treatment does not alter the subsequent incidence of secondary glomerulonephritis. Impetigo is very contagious among infants and young children and may be associated with poor hygiene or predisposing skin eruptions such as chicken pox, scabies, and atopic and contact dermatitis.
Scabies
11.20 Scabies
Presentation
Patients may rush to the emergency department shortly after having gone to bed, unable to sleep because of severe itching. Papules and vesicles (marking deposition of eggs) along thread-like tracks (mite burrows) are chiefly found in the interdigital web spaces as well as on the volar aspects of the wrists, antecubital fossa, olecranon area, nipples, umbilicus, lower abdomen, genitalia and gluteal cleft. Secondary bacterial infection is often present.
What to do:
Attempt identification of the mite by placing mineral oil over the papule or vesicle at the proximal end of a track and scraping it with a # 15 scalpel blade onto a microscope slide. Examine it under low magnification for either the mite or its oval eggs or fecal concretions.
If the clinical picture is convincing, treatment should be instituted without the help of microscopic examination, or even in the face of negative scrapings.
Treat with lindane (Kwell) lotion to the entire body from the neck down. Concentrate on the affected areas. The patient should apply this prescription medication and leave it on for 24 hours before washing it off (60-120ml is required for the average adult). It may be necessary to repeat this treatment after 1 week, but not sooner. Tell the patient that the itching will not go away at once, but that this does not mean the Kwell was ineffective. Dead mites and eggs continue to itch as they are absorbed by the body. An antipruritic agent such as hydroxyzine (Atarax) 25mg q6h can be prescribed for comfort.
Alternatively, treat with a similar application of crotamiton (Eurax) lotion or cream to the body after bathing, repeated after 24 hours. This treatment can also reduce itching.
Clothing, bedding, and towels should be washed with hot water or dry cleaned to prevent reinfection.
What not to do:
Do not use Kwell on infants, young children, or pregnant women. Up to 10% of this pesticide may be absorbed percutaneously, producing seizures or CNS toxicity, and therefore an alternative treatment should be sought. Crotamiton (Eurax) cream applied twice during a 48 hr period will be effective and also acts as an antipruritic agent.
Discussion
Scabies is caused by infestation with the mite Sarcoptes scabiei. The female mite, which is just visible to the human eye, excavates a burrow in the stratum corneum and travels about 2mm a day for about 1-2 months before dying. During this time she lays eggs which reach maturity in about 3 weeks. Scabies is transmitted principally through close personal contact, but may be transmitted through clothing, linens, or towels. Severe pruritis is probably caused by an acquired sensitivity to the organism and is first noted 2-4 weeks after primary infestation. Sometimes nonspecific, pruritic, generalized maculopapular excoriated rash, turns out, after a therapeutic trial of Kwell, to have heen an atypical case of scabies.
Presentation
Patients may rush to the emergency department shortly after having gone to bed, unable to sleep because of severe itching. Papules and vesicles (marking deposition of eggs) along thread-like tracks (mite burrows) are chiefly found in the interdigital web spaces as well as on the volar aspects of the wrists, antecubital fossa, olecranon area, nipples, umbilicus, lower abdomen, genitalia and gluteal cleft. Secondary bacterial infection is often present.
What to do:
Attempt identification of the mite by placing mineral oil over the papule or vesicle at the proximal end of a track and scraping it with a # 15 scalpel blade onto a microscope slide. Examine it under low magnification for either the mite or its oval eggs or fecal concretions.
If the clinical picture is convincing, treatment should be instituted without the help of microscopic examination, or even in the face of negative scrapings.
Treat with lindane (Kwell) lotion to the entire body from the neck down. Concentrate on the affected areas. The patient should apply this prescription medication and leave it on for 24 hours before washing it off (60-120ml is required for the average adult). It may be necessary to repeat this treatment after 1 week, but not sooner. Tell the patient that the itching will not go away at once, but that this does not mean the Kwell was ineffective. Dead mites and eggs continue to itch as they are absorbed by the body. An antipruritic agent such as hydroxyzine (Atarax) 25mg q6h can be prescribed for comfort.
Alternatively, treat with a similar application of crotamiton (Eurax) lotion or cream to the body after bathing, repeated after 24 hours. This treatment can also reduce itching.
Clothing, bedding, and towels should be washed with hot water or dry cleaned to prevent reinfection.
What not to do:
Do not use Kwell on infants, young children, or pregnant women. Up to 10% of this pesticide may be absorbed percutaneously, producing seizures or CNS toxicity, and therefore an alternative treatment should be sought. Crotamiton (Eurax) cream applied twice during a 48 hr period will be effective and also acts as an antipruritic agent.
Discussion
Scabies is caused by infestation with the mite Sarcoptes scabiei. The female mite, which is just visible to the human eye, excavates a burrow in the stratum corneum and travels about 2mm a day for about 1-2 months before dying. During this time she lays eggs which reach maturity in about 3 weeks. Scabies is transmitted principally through close personal contact, but may be transmitted through clothing, linens, or towels. Severe pruritis is probably caused by an acquired sensitivity to the organism and is first noted 2-4 weeks after primary infestation. Sometimes nonspecific, pruritic, generalized maculopapular excoriated rash, turns out, after a therapeutic trial of Kwell, to have heen an atypical case of scabies.
Pediculosis
11.19 Pediculosis (Lice, crabs)
Presentation
Picture
Patients arrive with emotions ranging from annoyance to sheer disgust at the discovery of an infestation with lice or crabs and request acute medical care. There may be extreme pruritis and the patient may bring in a sample of the creature to show you. The adult forms of head lice (pediculosis) can be very difficult to find but their oval, light gray eggs (nits) can be readily found firmly attached to the hairs above the ears and toward the occiput. Secondary impetigo and furunculosis can occur. The adult forms of pubic lice (pthirus or crab lice) are more easily found, but their light yellow gray color still makes them difficult to see. Small black dots present in infested areas represent either ingested blood in adult lice or their excreta.
What to do:
Instruct the patient and other close contacts on the use of pyrethrins with piperonyl butoxide (RID), an over-the- counter louse remedy which should be applied undiluted to the hair until the affected area is entirely wet. After 10 minutes the infested area should be shampooed and thoroughly rinsed with warm water. This treatment may be repeated if necessary, but it should not be used more than twice within a 24 hr period and it is advisable to wait a week before repeating treatment should reinfestation occur.
Alternatively, try one application of permethrin 1% cream rinse.
Families should also be instructed to disinfect sheets and clothing by machine washing in hot water, machine drying on the hot cycle for 20 minutes, ironing, dry cleaning, or storage in plastic bags for two weeks. Combs and brushes should be soaked in 2% Lysol or heated in water to about 65 degrees C for 10 minutes.
Application of a 1:1 solution of white vinegar and water may help to loosen nits prior to removal with a fine- toothed comb.
What not to do:
Do not have the family use commercial sprays (R&C Spray or Li-Ban Spray) to control lice on inanimate objects. Their use is no more effective than vacuuming.
Do not let patients use lindane (Kwell) shampoo on mucous membranes, around the eyes, on acutely inflamed areas, and do not prescribe it for pregnant women and infants. It is absorbed and can be toxic to the central nervous system.
Discussion
Head and pubic lice are obligatory bloodsucking ectoparasites whose eggs are firmly attached to the hair shafts near the skin, and incubate for about a week before hatching. Nits located more than one-half inch from the scalp are no longer viable.
A common alternate treatment for lice is lindane shampoo which is only available by prescription. One ounce is worked into the affected area for four minutes and then thoroughly rinsed out. Because of the very toxic nature of lindane, its use should be reserved for those cases that fail to respond to pyrethrins (RID). Treatment with either substance may not be ovicidal and therefore re-treatment after 7 to 10 days is often recommended.
Presentation
Picture
Patients arrive with emotions ranging from annoyance to sheer disgust at the discovery of an infestation with lice or crabs and request acute medical care. There may be extreme pruritis and the patient may bring in a sample of the creature to show you. The adult forms of head lice (pediculosis) can be very difficult to find but their oval, light gray eggs (nits) can be readily found firmly attached to the hairs above the ears and toward the occiput. Secondary impetigo and furunculosis can occur. The adult forms of pubic lice (pthirus or crab lice) are more easily found, but their light yellow gray color still makes them difficult to see. Small black dots present in infested areas represent either ingested blood in adult lice or their excreta.
What to do:
Instruct the patient and other close contacts on the use of pyrethrins with piperonyl butoxide (RID), an over-the- counter louse remedy which should be applied undiluted to the hair until the affected area is entirely wet. After 10 minutes the infested area should be shampooed and thoroughly rinsed with warm water. This treatment may be repeated if necessary, but it should not be used more than twice within a 24 hr period and it is advisable to wait a week before repeating treatment should reinfestation occur.
Alternatively, try one application of permethrin 1% cream rinse.
Families should also be instructed to disinfect sheets and clothing by machine washing in hot water, machine drying on the hot cycle for 20 minutes, ironing, dry cleaning, or storage in plastic bags for two weeks. Combs and brushes should be soaked in 2% Lysol or heated in water to about 65 degrees C for 10 minutes.
Application of a 1:1 solution of white vinegar and water may help to loosen nits prior to removal with a fine- toothed comb.
What not to do:
Do not have the family use commercial sprays (R&C Spray or Li-Ban Spray) to control lice on inanimate objects. Their use is no more effective than vacuuming.
Do not let patients use lindane (Kwell) shampoo on mucous membranes, around the eyes, on acutely inflamed areas, and do not prescribe it for pregnant women and infants. It is absorbed and can be toxic to the central nervous system.
Discussion
Head and pubic lice are obligatory bloodsucking ectoparasites whose eggs are firmly attached to the hair shafts near the skin, and incubate for about a week before hatching. Nits located more than one-half inch from the scalp are no longer viable.
A common alternate treatment for lice is lindane shampoo which is only available by prescription. One ounce is worked into the affected area for four minutes and then thoroughly rinsed out. Because of the very toxic nature of lindane, its use should be reserved for those cases that fail to respond to pyrethrins (RID). Treatment with either substance may not be ovicidal and therefore re-treatment after 7 to 10 days is often recommended.
Shingles
11.18 Herpes Zoster (Shingles)
Presentation: Patients complain of pain, paresthesia, or an itch that covers a specific dermatome and then develops into a characteristic rash. Prior to the onset of the rash, zoster can be confused with pleuritic or cardiac pain, cholecystitis, or ureteral colic. Approximately 3-5 days from the onset of symptoms, an eruption of erythematous macules and papules will appear, first posteriorly then spreading anteriorly along the course of the involved nerve segment. In most instances grouped vesicles will appear within the next 24 hours. Herpes zoster most often occurs in the thoracic and cervical segments.
What to do:
Prescribe acyclovir (Zovirax) 800mg q4h (five times a day, skip a dose at night) or famiclovir (Famvir) 500mg tid x7d.
Prescribe analgesics appropriate for the level of pain the patient is experiencing. Anti-inflammatory medications may help, but narcotics are often required (e.g., Percocet q4h).
Cool compresses with Burow's solution will be comforting (e.g Domeboro powder, 2 pkts in 1 pint of water).
Dressing the lesions with gauze and splinting them with an elastic wrap may also help bring relief.
Secondary infection should be treated with povidone-iodine (Betadine) ointment or systemic antibiotics.
Ocular lesions should be evaluated by an ophthalmologist and treated with topical ophthalmic corticosteroids. Although topical steroids are contraindicated in herpes simplex keratitis, because they allow deeper corneal injury, this does not appear to be a problem with herpes zoster ophthalmicus. If the rash extends to the tip of the nose, the eye will probably be involved, because it is served by the same ophthalmic branch of the trigeminal nerve.
What not to do:
Do not prescribe systemic steroids to prevent post herpetic neuralgia, especially for patients at high risk, i.e., with latent tuberculosis, peptic ulcer, diabetes mellitus, hypertension, and congestive heart failure.
Discussion
Zoster results from reactivation of latent herpes varicella/zoster (chickenpox) virus residing in dorsal root or cranial nerve ganglion cells. Two-thirds of the patients are over 40 years old. This is a self-limiting, localized disease and usually heals within 3-4 weeks. Postherpetic neuralgia in patients over 60 years old, however, can be an extremely painful, recurrent misery. Before the availability of anti-viral agents, the best prophylaxis was systemic corticosteroids, but these have not been shown to improve outcome when added to a week of anti-viral treatment.
References:
Wood MJ, Johnson RW, McKendrick MW, Taylor J, Mandal BK, Crooks J: A randomized trial of acyclovir for 7 days or 21 days with and without prednisolone for treatment of acute herpes zoster. N Eng J Med 1994;330:896-900.
Presentation: Patients complain of pain, paresthesia, or an itch that covers a specific dermatome and then develops into a characteristic rash. Prior to the onset of the rash, zoster can be confused with pleuritic or cardiac pain, cholecystitis, or ureteral colic. Approximately 3-5 days from the onset of symptoms, an eruption of erythematous macules and papules will appear, first posteriorly then spreading anteriorly along the course of the involved nerve segment. In most instances grouped vesicles will appear within the next 24 hours. Herpes zoster most often occurs in the thoracic and cervical segments.
What to do:
Prescribe acyclovir (Zovirax) 800mg q4h (five times a day, skip a dose at night) or famiclovir (Famvir) 500mg tid x7d.
Prescribe analgesics appropriate for the level of pain the patient is experiencing. Anti-inflammatory medications may help, but narcotics are often required (e.g., Percocet q4h).
Cool compresses with Burow's solution will be comforting (e.g Domeboro powder, 2 pkts in 1 pint of water).
Dressing the lesions with gauze and splinting them with an elastic wrap may also help bring relief.
Secondary infection should be treated with povidone-iodine (Betadine) ointment or systemic antibiotics.
Ocular lesions should be evaluated by an ophthalmologist and treated with topical ophthalmic corticosteroids. Although topical steroids are contraindicated in herpes simplex keratitis, because they allow deeper corneal injury, this does not appear to be a problem with herpes zoster ophthalmicus. If the rash extends to the tip of the nose, the eye will probably be involved, because it is served by the same ophthalmic branch of the trigeminal nerve.
What not to do:
Do not prescribe systemic steroids to prevent post herpetic neuralgia, especially for patients at high risk, i.e., with latent tuberculosis, peptic ulcer, diabetes mellitus, hypertension, and congestive heart failure.
Discussion
Zoster results from reactivation of latent herpes varicella/zoster (chickenpox) virus residing in dorsal root or cranial nerve ganglion cells. Two-thirds of the patients are over 40 years old. This is a self-limiting, localized disease and usually heals within 3-4 weeks. Postherpetic neuralgia in patients over 60 years old, however, can be an extremely painful, recurrent misery. Before the availability of anti-viral agents, the best prophylaxis was systemic corticosteroids, but these have not been shown to improve outcome when added to a week of anti-viral treatment.
References:
Wood MJ, Johnson RW, McKendrick MW, Taylor J, Mandal BK, Crooks J: A randomized trial of acyclovir for 7 days or 21 days with and without prednisolone for treatment of acute herpes zoster. N Eng J Med 1994;330:896-900.
Tinea
11.17 Tinea (Athlete's Foot, ringworm)
Presentation
Patients usually seek emergency care for "athlete's foot," "jock itch," or "ringworm" when pruritis is severe or when secondary infection causes pain and swelling. Tinea pedis is usually seen as interdigital scaling, maceration, and fissuring between toes. At times tense vesicular lesions will be present instead. Tinea cruris is usually a moist, mildly erythematous eruption symmetrically affecting both groin and upper inner thigh. Tinea corporis appears most often on the hairless skin of children as dry erythematous lesions with sharp annular and arciform borders that are scaling or vesicular.
What to do:
When microscopic examination of skin scrapings in KOH is readily available, definite identification of the lesion can be made by looking for the presence of hyphae or spores (resembling microscopic spaghetti and meatballs) in the scabs or hair. Treatment can be started presumptively when microscopic examination is not easily accomplished.
Clotrimazole (Lotrimin), miconazole (Micatin) haloprogin (Halotex) and tolnaftate (Tinactin) solution or cream applied to the rash bid will cause involution of most superficial lesions within 1-2 weeks.
With signs of secondary infection, begin treatment first with wet compresses of Burow's solution (2 pks of Domeboro powder in 1 pint water) one half hour every 34 hours. With signs of deep infection (cellulitis, lymphangitis) begin systemic antibiotics in addition, like cefadroxil (Duricef) lgm qd x 5-7 day or cephalexin or dicloxacillin 250-500mg tid x 5-7 days.
With inflammation and weeping lesions, a topical antifungal and steroid cream such as (Vioform- Hydrocortisone) in addition to the compresses will be most effective. Warn patients that this medication will stain white clothing yellow.
What not to do:
Do not attempt to treat deep, painful fungal infections of the scalp (tinea capitis) with local therapy. A deep boggy swelling (tinea kerion) or patchy hair loss with inflammation and scaling requires systemic antifungal antibiotics like griseofulvin.
Do not treat with corticosteroids alone. They will reduce signs and symptoms, but allow increased fungal growth.
Discussion
Tinea versicolor is asymptomatic, and its presentation to an acute care facility usually is incidental with some other problem. There is, however, no reason to ignore this fungal infection, which causes cosmetically unpleasant, irregular patches of varying pigmentation that tend to be lighter than the surrounding skin in the summer and darker than the surrounding skin in the winter. Prescribe a 25% sodium hyposulfite lotion (Tinver) bid for several weeks or a 2.5% selenium sulfide lotion (Selsun). Superficial scaling will resolve in a few days and the pigmentary changes will slowly clear over a period of several months.
Presentation
Patients usually seek emergency care for "athlete's foot," "jock itch," or "ringworm" when pruritis is severe or when secondary infection causes pain and swelling. Tinea pedis is usually seen as interdigital scaling, maceration, and fissuring between toes. At times tense vesicular lesions will be present instead. Tinea cruris is usually a moist, mildly erythematous eruption symmetrically affecting both groin and upper inner thigh. Tinea corporis appears most often on the hairless skin of children as dry erythematous lesions with sharp annular and arciform borders that are scaling or vesicular.
What to do:
When microscopic examination of skin scrapings in KOH is readily available, definite identification of the lesion can be made by looking for the presence of hyphae or spores (resembling microscopic spaghetti and meatballs) in the scabs or hair. Treatment can be started presumptively when microscopic examination is not easily accomplished.
Clotrimazole (Lotrimin), miconazole (Micatin) haloprogin (Halotex) and tolnaftate (Tinactin) solution or cream applied to the rash bid will cause involution of most superficial lesions within 1-2 weeks.
With signs of secondary infection, begin treatment first with wet compresses of Burow's solution (2 pks of Domeboro powder in 1 pint water) one half hour every 34 hours. With signs of deep infection (cellulitis, lymphangitis) begin systemic antibiotics in addition, like cefadroxil (Duricef) lgm qd x 5-7 day or cephalexin or dicloxacillin 250-500mg tid x 5-7 days.
With inflammation and weeping lesions, a topical antifungal and steroid cream such as (Vioform- Hydrocortisone) in addition to the compresses will be most effective. Warn patients that this medication will stain white clothing yellow.
What not to do:
Do not attempt to treat deep, painful fungal infections of the scalp (tinea capitis) with local therapy. A deep boggy swelling (tinea kerion) or patchy hair loss with inflammation and scaling requires systemic antifungal antibiotics like griseofulvin.
Do not treat with corticosteroids alone. They will reduce signs and symptoms, but allow increased fungal growth.
Discussion
Tinea versicolor is asymptomatic, and its presentation to an acute care facility usually is incidental with some other problem. There is, however, no reason to ignore this fungal infection, which causes cosmetically unpleasant, irregular patches of varying pigmentation that tend to be lighter than the surrounding skin in the summer and darker than the surrounding skin in the winter. Prescribe a 25% sodium hyposulfite lotion (Tinver) bid for several weeks or a 2.5% selenium sulfide lotion (Selsun). Superficial scaling will resolve in a few days and the pigmentary changes will slowly clear over a period of several months.
Thursday 8 August 2013
Pityriasis Rosea
11.16 Pityriasis Rosea
Presentation
Patients with this benign disorder often seek acute medical help because of the worrisome sudden spread of a rash that began with one local skin lesion. This "herald patch" may develop anywhere on the body and appears as a round 2-6 cm mildly erythematous scaling plaque. There is no change for a period of several days to two weeks; then the rash appears, composed of small (l-2cm), pale, salmon-colored, oval macules or plaques with a coarse surface surrounded by a rim of fine scales. The distribution is truncal with the long axis of the oval lesions running in the planes of cleavage of the skin (parallel to the ribs). The condition may be asymptomatic or accompanied by varying degrees of pruritis and, occasionally mild malaise. The lesions will gradually extend in size and may become confluent with one another. The rash persists for 6-8 week then completely disappears. Recurrences are uncommon.
What to do:
Reassure the patient about the benign nature of this disease. Be sympathetic and let him know that you understand how frightening it can seem.
Draw blood for serologic testing for syphilis (e.g., VDRL). Secondary syphilis can mimic pityriasis rosea. Make a note to track down the results of the test.
Provide relief from pruritis by prescribing hydroxyzine (Atarax) 50mg q6h or an emollient such as Lubriderm. Tepid corn starch baths (1 cup in 1/2 tub of water) may also be comforting.
Inform the patient that he should anticipate a 6-8 week course of the disease, but to seek followup care if the rash does not resolve within 12 weeks.
What not to do:
Do not use topical or systemic steroids. These are only effective in the most severe inflammatory varieties of this syndrome.
Do not send off a serologic test for syphilis without assuring the results will be seen and acted upon.
Discussion
Pityriasis rosea is seen most commonly in adolescents and young adults during the spring and fall seasons. It is probably a viral syndrome. The "herald patch" may not be seen in 20-30% of the cases and there are many variations from the classic presentation described. Other diagnostic considerations besides syphilis include tinea corporis, seborrheic dermatitis, acute psoriasis, and tinea versicolor.
Presentation
Patients with this benign disorder often seek acute medical help because of the worrisome sudden spread of a rash that began with one local skin lesion. This "herald patch" may develop anywhere on the body and appears as a round 2-6 cm mildly erythematous scaling plaque. There is no change for a period of several days to two weeks; then the rash appears, composed of small (l-2cm), pale, salmon-colored, oval macules or plaques with a coarse surface surrounded by a rim of fine scales. The distribution is truncal with the long axis of the oval lesions running in the planes of cleavage of the skin (parallel to the ribs). The condition may be asymptomatic or accompanied by varying degrees of pruritis and, occasionally mild malaise. The lesions will gradually extend in size and may become confluent with one another. The rash persists for 6-8 week then completely disappears. Recurrences are uncommon.
What to do:
Reassure the patient about the benign nature of this disease. Be sympathetic and let him know that you understand how frightening it can seem.
Draw blood for serologic testing for syphilis (e.g., VDRL). Secondary syphilis can mimic pityriasis rosea. Make a note to track down the results of the test.
Provide relief from pruritis by prescribing hydroxyzine (Atarax) 50mg q6h or an emollient such as Lubriderm. Tepid corn starch baths (1 cup in 1/2 tub of water) may also be comforting.
Inform the patient that he should anticipate a 6-8 week course of the disease, but to seek followup care if the rash does not resolve within 12 weeks.
What not to do:
Do not use topical or systemic steroids. These are only effective in the most severe inflammatory varieties of this syndrome.
Do not send off a serologic test for syphilis without assuring the results will be seen and acted upon.
Discussion
Pityriasis rosea is seen most commonly in adolescents and young adults during the spring and fall seasons. It is probably a viral syndrome. The "herald patch" may not be seen in 20-30% of the cases and there are many variations from the classic presentation described. Other diagnostic considerations besides syphilis include tinea corporis, seborrheic dermatitis, acute psoriasis, and tinea versicolor.
Urticaria
11.15 Urticaria (Hives)
Presentation
The patient is generally very uncomfortable, with intense itching. There may be a history of similar episodes and perhaps a known precipitating agent (bee sting, food, or drug). Most commonly the patient will only have a rash. Sometimes this is accompanied by edematous swelling of the lips, face and/or hands (angioedema). In the more severe cases, patients may have wheezing, laryngeal edema and/or frank cardiovascular collapse (anaphylaxis). The urticarial rash consists of sharply defined, slightly raised wheals surrounded by erythema and tending to be circular or serpiginous. Each eruption is transient, lasting no more than 8-12 hours, but it may be replaced by new lesions in different locations.
What to do:
Attempt to elicit a precipitating cause, including drugs, foods, stress, or an underlying infection or illness, (e.g., collagen vascular disease, malignancy, or, when accompanied by arthralgias, anicteric hepatitis).
For immediate relief of severe pruritis, you can try 0.3cc of epinephrine (1:1000) subcutaneously, but this wears off quickly, and adds a number of side effects the patient may find worse than the itching: tachycardia, shaking, dry mouth, wet palms, hypertension, and even angina and myocardial infarction.
For continued relief administer diphenhydramine (Benadryl) or hydroxyzine (Vistaril) 50mg po.
For prolonged relief from itching prescribe diphenhydramine (Benadryl), hydroxyzine (Atarax) 25-50mg, cyproheptadine hydrochloride (Periactin) 4mg qid or terfenadine (Seldane) 60mg bidfor the next 48 hours.
To reduce the rash, prescribe cimetidine (Tagamet) 300mg q6h. Other H2 blockers, such as ranitidine (Zantac) and nizatidine (Axid) also appear to work in similar doses.
To blunt the entire allergic process, give prednisone 60mg po now and prescribe 20mg qd for 2 days.
Inform the patient that the cause of hives cannot be determined in the vast majority of cases. Let him know that the condition is usually of minor consequence but can at times become chronic, and, under unusual circumstances, is associated with other illnesses. Therefore, the patient should be provided with elective followup care.
What not to do:
Do not havethe patient take aspirin. Some patients experience a worsening of their symptoms with the use of aspirin. Morphine, codeine, reserpine, and alcohol, as well as certain food additives such as tartrazine dye, are often allergens or potentiate allergic reactions, and benzoates should probably also be avoided.
Discussion
Although the treatment of anaphylactic shock is beyond the scope of this book, when hypotension is present, aggressive intravenous fluid therapy should be instituted, along with the intravenous administration of the medications above. Simple urticaria affects approximately 20% of the population at some time. This local reaction is due at least in part to the release of histamines and other vasoactive peptides from mast cells following an IgE mediated antigen- antibody reaction. This results in vasodilatation and increased vascular permeability, with the leaking of protein and fluid into extravascular spaces. The heavier concentration of mast cells within the lips, face, and hands explains why these areas are more commonly affected. In asthma, the bronchial tree is more affected, whereas with eczema, the skin in knee and elbow creases is most heavily invested with mast cells and the first to develop hives.
References:
Rusli M: Cimetidine treatment of recalcitrant acute allergic urticaria. Ann Emerg Med 1986;15:1363-1365.
Presentation
The patient is generally very uncomfortable, with intense itching. There may be a history of similar episodes and perhaps a known precipitating agent (bee sting, food, or drug). Most commonly the patient will only have a rash. Sometimes this is accompanied by edematous swelling of the lips, face and/or hands (angioedema). In the more severe cases, patients may have wheezing, laryngeal edema and/or frank cardiovascular collapse (anaphylaxis). The urticarial rash consists of sharply defined, slightly raised wheals surrounded by erythema and tending to be circular or serpiginous. Each eruption is transient, lasting no more than 8-12 hours, but it may be replaced by new lesions in different locations.
What to do:
Attempt to elicit a precipitating cause, including drugs, foods, stress, or an underlying infection or illness, (e.g., collagen vascular disease, malignancy, or, when accompanied by arthralgias, anicteric hepatitis).
For immediate relief of severe pruritis, you can try 0.3cc of epinephrine (1:1000) subcutaneously, but this wears off quickly, and adds a number of side effects the patient may find worse than the itching: tachycardia, shaking, dry mouth, wet palms, hypertension, and even angina and myocardial infarction.
For continued relief administer diphenhydramine (Benadryl) or hydroxyzine (Vistaril) 50mg po.
For prolonged relief from itching prescribe diphenhydramine (Benadryl), hydroxyzine (Atarax) 25-50mg, cyproheptadine hydrochloride (Periactin) 4mg qid or terfenadine (Seldane) 60mg bidfor the next 48 hours.
To reduce the rash, prescribe cimetidine (Tagamet) 300mg q6h. Other H2 blockers, such as ranitidine (Zantac) and nizatidine (Axid) also appear to work in similar doses.
To blunt the entire allergic process, give prednisone 60mg po now and prescribe 20mg qd for 2 days.
Inform the patient that the cause of hives cannot be determined in the vast majority of cases. Let him know that the condition is usually of minor consequence but can at times become chronic, and, under unusual circumstances, is associated with other illnesses. Therefore, the patient should be provided with elective followup care.
What not to do:
Do not havethe patient take aspirin. Some patients experience a worsening of their symptoms with the use of aspirin. Morphine, codeine, reserpine, and alcohol, as well as certain food additives such as tartrazine dye, are often allergens or potentiate allergic reactions, and benzoates should probably also be avoided.
Discussion
Although the treatment of anaphylactic shock is beyond the scope of this book, when hypotension is present, aggressive intravenous fluid therapy should be instituted, along with the intravenous administration of the medications above. Simple urticaria affects approximately 20% of the population at some time. This local reaction is due at least in part to the release of histamines and other vasoactive peptides from mast cells following an IgE mediated antigen- antibody reaction. This results in vasodilatation and increased vascular permeability, with the leaking of protein and fluid into extravascular spaces. The heavier concentration of mast cells within the lips, face, and hands explains why these areas are more commonly affected. In asthma, the bronchial tree is more affected, whereas with eczema, the skin in knee and elbow creases is most heavily invested with mast cells and the first to develop hives.
References:
Rusli M: Cimetidine treatment of recalcitrant acute allergic urticaria. Ann Emerg Med 1986;15:1363-1365.
Contusions
11.14 Contusions (Bruises)
Presentation
The patient has fallen, has been thrown against an object or has been struck at a site where now there is point tenderness, swelling, ecchymosis, hematoma, or pain with use. On physical examination, there is no loss of function of muscles and tendons (beyond mild splinting because of pain), no instability of bones and ligaments, and no crepitus or tenderness produced by remote stress (such as weight-bearing on the leg or manual flexing of a rib).
What to do:
Take a thorough history to ascertain the mechanism of injury and perform a complete examination to document structural integrity and intact function.
Reserve x rays for possible foreign bodies and bony injury. Fractures are uncommon after a direct blow, but are suggested by pain with remote percussion or stressing of bone or an underlying deformity or crepitus. The yield is very low when x rays are ordered on the basis of pain and swelling alone.
Explain to the patient that swelling will peak in 1 day, then resolve gradually, and that swelling, stiffness and pain may be reduced by good treatment during the first 1-2 days.
Prescribe:
resting the affected part,immobilization (the ultimate in rest, best achieved with a splint),elevation of the affected part (ideally, above the level of the heart), and
cold (usually an ice bag, wrapped in a towel, applied to the injury for 10-20 minutes per hour for the first 24 hours).
Explain to the patient the late migration and color change of ecchymoses, so that green or purple discoloration appearing farther down the limb a week after the injury does not frighten him into thinking he has another injury.
Large intramuscular hematomas (especially of the anterior thigh) may require drainage or orthopedic consultation.
Arrange for re-evaluation and followup if there is any continued or increasing discomfort.
What not to do:
Do not apply an elastic bandage to the middle of a limb, where it may act as a tourniquet. Include all of the distal limb in the wrapping if a compression dressing is necessary.
Do not confuse patients with instructions for application of heat and exercises to prevent stiffness and atrophy. Concentrate on the here-and-now therapy of the acute injury; namely, rest, immobilization, elevation, and cold: all designed to decrease acute edema. Leave other instructions to followup and . physical therapy consultants. Patients who confuse today's correct therapy with next week's can complicate their problem.
Do not take for granted that all of your patients understand rest, immobilization, elevation, and cold. Walking on a fresh foot injury or soaking it for long periods in ice water or Epsom salts are not usually therapeutic.
Discussion
The acute therapy of contusions concentrates upon reduction of the acute edema, and all other components of treatment are postponed for 3-4 days, until the inflammation and edema are reduced. Patients need to know this time course, and must understand that the more the swelling can be reduced, the sooner injuries can heal, function return and pain decrease. Edema of hands and feet is especially slow to resolve, because these structures usually hang in a dependent position, and require much modification of activity to rest.
Presentation
The patient has fallen, has been thrown against an object or has been struck at a site where now there is point tenderness, swelling, ecchymosis, hematoma, or pain with use. On physical examination, there is no loss of function of muscles and tendons (beyond mild splinting because of pain), no instability of bones and ligaments, and no crepitus or tenderness produced by remote stress (such as weight-bearing on the leg or manual flexing of a rib).
What to do:
Take a thorough history to ascertain the mechanism of injury and perform a complete examination to document structural integrity and intact function.
Reserve x rays for possible foreign bodies and bony injury. Fractures are uncommon after a direct blow, but are suggested by pain with remote percussion or stressing of bone or an underlying deformity or crepitus. The yield is very low when x rays are ordered on the basis of pain and swelling alone.
Explain to the patient that swelling will peak in 1 day, then resolve gradually, and that swelling, stiffness and pain may be reduced by good treatment during the first 1-2 days.
Prescribe:
resting the affected part,immobilization (the ultimate in rest, best achieved with a splint),elevation of the affected part (ideally, above the level of the heart), and
cold (usually an ice bag, wrapped in a towel, applied to the injury for 10-20 minutes per hour for the first 24 hours).
Explain to the patient the late migration and color change of ecchymoses, so that green or purple discoloration appearing farther down the limb a week after the injury does not frighten him into thinking he has another injury.
Large intramuscular hematomas (especially of the anterior thigh) may require drainage or orthopedic consultation.
Arrange for re-evaluation and followup if there is any continued or increasing discomfort.
What not to do:
Do not apply an elastic bandage to the middle of a limb, where it may act as a tourniquet. Include all of the distal limb in the wrapping if a compression dressing is necessary.
Do not confuse patients with instructions for application of heat and exercises to prevent stiffness and atrophy. Concentrate on the here-and-now therapy of the acute injury; namely, rest, immobilization, elevation, and cold: all designed to decrease acute edema. Leave other instructions to followup and . physical therapy consultants. Patients who confuse today's correct therapy with next week's can complicate their problem.
Do not take for granted that all of your patients understand rest, immobilization, elevation, and cold. Walking on a fresh foot injury or soaking it for long periods in ice water or Epsom salts are not usually therapeutic.
Discussion
The acute therapy of contusions concentrates upon reduction of the acute edema, and all other components of treatment are postponed for 3-4 days, until the inflammation and edema are reduced. Patients need to know this time course, and must understand that the more the swelling can be reduced, the sooner injuries can heal, function return and pain decrease. Edema of hands and feet is especially slow to resolve, because these structures usually hang in a dependent position, and require much modification of activity to rest.
Wednesday 7 August 2013
Zipper Caught on Penis or Chin
11.13 Zipper Caught on Penis or Chin
Presentation
Usually a child has gotten dressed too quickly and not wearing underpants, accidentally pulled up penile skin into his zipper. The skin becomes entrapped and crushed between the teeth and the slide of the zipper, thereby painfully attaching the article of clothing to the body part involved (most often the penis or less often the area beneath the chin).
What to do:
Paint the area with a small amount of povidone-iodine and infiltrate the skin with 1% lidocaine (plain). This will allow the comfortable manipulation of the zipper and the article of clothing.
Cover the area with mineral oil. This lubricates the moving parts and often frees the skin without having to cut the zipper.
If the mineral oil alone does not work, then cut the zipper away from the article of clothing to leave yourself with a less cumbersome problem.
Cut the slide of the zipper in half with a pair of metal snips or an orthopedic pin cutter. The patient is less likely to be frightened if this procedure is kept hidden from his view. If you are unable to break the two halves of the zipper slide apart using a metal cutter, then take two heavy duty surgical towel clamps and place their tongs into the side grooves at both ends of the slide. then grip one clamp firmly in each hand and then twist your wrists in opposite directions. This often will pop the two halves of the zipper slide apart, releasing the entrapped skin.
Pull the exposed zipper teeth apart, cleanse the crushed skin, and apply an ointment such as povidone-iodine.
Tetanus prophylaxis should be administered as needed.
What not to do:
Do not cut clothing if mineral oil releases the zipper.
Do not destroy the entire article of clothing by cutting into it. You only need to cut the zipper away allowing repair of the clothing.
Do not excise an area of skin or perform a circumcision; it onlv creates unnecessary morbidity for the patient.
Discussion
Newer plastic zippers have made this problem less common than in the past, but it still occurs, and it is a very grateful patient who is released from this entrapment.
References:
Nolan JF, Stillwell TJ, Sands JP: Acute management of the zipper-entrapped penis. J Emerg Med 1990;8:305-307.
Kanegaye JT, Schonfeld N: Penile zipper entrapment: a simple and less threatening approach using mineral oil. Pediatric Emergency Care 1993;9:90-91.
Presentation
Usually a child has gotten dressed too quickly and not wearing underpants, accidentally pulled up penile skin into his zipper. The skin becomes entrapped and crushed between the teeth and the slide of the zipper, thereby painfully attaching the article of clothing to the body part involved (most often the penis or less often the area beneath the chin).
What to do:
Paint the area with a small amount of povidone-iodine and infiltrate the skin with 1% lidocaine (plain). This will allow the comfortable manipulation of the zipper and the article of clothing.
Cover the area with mineral oil. This lubricates the moving parts and often frees the skin without having to cut the zipper.
If the mineral oil alone does not work, then cut the zipper away from the article of clothing to leave yourself with a less cumbersome problem.
Cut the slide of the zipper in half with a pair of metal snips or an orthopedic pin cutter. The patient is less likely to be frightened if this procedure is kept hidden from his view. If you are unable to break the two halves of the zipper slide apart using a metal cutter, then take two heavy duty surgical towel clamps and place their tongs into the side grooves at both ends of the slide. then grip one clamp firmly in each hand and then twist your wrists in opposite directions. This often will pop the two halves of the zipper slide apart, releasing the entrapped skin.
Pull the exposed zipper teeth apart, cleanse the crushed skin, and apply an ointment such as povidone-iodine.
Tetanus prophylaxis should be administered as needed.
What not to do:
Do not cut clothing if mineral oil releases the zipper.
Do not destroy the entire article of clothing by cutting into it. You only need to cut the zipper away allowing repair of the clothing.
Do not excise an area of skin or perform a circumcision; it onlv creates unnecessary morbidity for the patient.
Discussion
Newer plastic zippers have made this problem less common than in the past, but it still occurs, and it is a very grateful patient who is released from this entrapment.
References:
Nolan JF, Stillwell TJ, Sands JP: Acute management of the zipper-entrapped penis. J Emerg Med 1990;8:305-307.
Kanegaye JT, Schonfeld N: Penile zipper entrapment: a simple and less threatening approach using mineral oil. Pediatric Emergency Care 1993;9:90-91.
Pyogenic Granuloma
11.12 Pyogenic Granuloma (Proud Flesh)
Presentation
Often there is a history of a laceration several days to a few weeks before presentation in the ED. The wound has not healed and now bleeds with every slight trauma. Objective findings usually include a crusted, sometimes purulent collection of friable granulation tissue arising from a moist, Some times hemorrhagic wound. There are usually no signs of a deep tissue infection.
What to do:
Cleanse the area with hydrogen peroxide and povidone-iodine solution.
Cauterize the granulation tissue with a silver nitrate stick until it is completely discolored.
Dress the wound after applying povidone-iodine ointment and have the patient repeat ointment and dressings 2-3 times per day until healed.
Warn the patient about the potential signs of developing infection.
What not to do:
Do not cauterize any lesion that by history and appearance might be neoplastic in nature. These lesions should be referred for complete excision and pathologic examination.
Do not cauterize a large or extensive lesion. These should also be completely excised.
Discussion
It is not uncommon for a secondary cellulitis to develop after cauterizing the granuloma. It is therefore reasonable to place a patient on a short course (3-4 days) of a high dose antibiotic (dicloxicillin or cephalexin 500mg tid or cefadroxil lgm qd) when the wound is located on a distal extremity.
Presentation
Often there is a history of a laceration several days to a few weeks before presentation in the ED. The wound has not healed and now bleeds with every slight trauma. Objective findings usually include a crusted, sometimes purulent collection of friable granulation tissue arising from a moist, Some times hemorrhagic wound. There are usually no signs of a deep tissue infection.
What to do:
Cleanse the area with hydrogen peroxide and povidone-iodine solution.
Cauterize the granulation tissue with a silver nitrate stick until it is completely discolored.
Dress the wound after applying povidone-iodine ointment and have the patient repeat ointment and dressings 2-3 times per day until healed.
Warn the patient about the potential signs of developing infection.
What not to do:
Do not cauterize any lesion that by history and appearance might be neoplastic in nature. These lesions should be referred for complete excision and pathologic examination.
Do not cauterize a large or extensive lesion. These should also be completely excised.
Discussion
It is not uncommon for a secondary cellulitis to develop after cauterizing the granuloma. It is therefore reasonable to place a patient on a short course (3-4 days) of a high dose antibiotic (dicloxicillin or cephalexin 500mg tid or cefadroxil lgm qd) when the wound is located on a distal extremity.
Erysipelas
11.11 Erysipelas Cellulitis Lymphangitis
Presentation
The cardinal signs of infection (pain, redness, warmth, and swelling) are present. Erysipelas is very superficial and bright red with indurated, sharply demarcated borders. Cellulitis is deeper, involves the subcutaneous connective tissue, and has an indistinct advancing border. Lymphangitis has minimal induration and an unmistakable linear pattern ascending along lymphatic channels. These superficial skin infections are often preceded by minor trauma or the presence of a foreign body, and are most common in patients who have predisposing factors such as diabetes, arterial or venous insufficiency, and lymphatic drainage obstruction. They may be associated with an abscess or they may have no clear-cut origin. With any of these skin infections the patient may have tender lymphadenopathy proximal to the site of infection and may or may not have signs of systemic toxicity (fever, rigors, and listlessness)
What to do:
Look for a possible source of infection and remove it. Debride and cleanse any wound, remove any foreign body or drain any abscess.
When the patient is very sick, or there is discoloration of the entire limb, get medical consultation and prepare for hospitalization. Obtain a CBC and blood cultures and get x rays to look for gas-forming organisms. Hospitalization should also be strongly considered when deep facial cellulitis is present or the patient has a deep i,nfection of the hand.
If there is low-grade fever, or none at all, you can usually treat on an outpatient basis. Prescribe dicloxacillin 500mg qid x 10d, cephalexin 500mg tid x 10d or cefadroxil lgm qd x 10d. Instruct the patient to keep the infected part at rest and elevated and to use intermittent warm moist compresses.
Followup within 24-48 hours to insure that the therapy has been adequate. Infections still worsening after 48 hours of outpatient treatment may require hospital admission for better immobilization, elevation, and intravenous antibiotics.
Discussion
The most common etiologic agents are beta hemolytic streptococci or Staphylococcus aureus. Erysipelas and lymphangitis are often a result of Group A strep alone although S. aureus may produce a similar picture. H. influenzae should be considered in the toxic child with facial cellulitis. It may be easier to evaluate on followup whether a cellulitis is improving or not if the initial margin of redness, swelling, tenderness, or warmth was marked on the skin with a ball point pen. Because response to treatment is often equivocal at 24 hours, reevaluation is usually best scheduled at 48 hours.
Presentation
The cardinal signs of infection (pain, redness, warmth, and swelling) are present. Erysipelas is very superficial and bright red with indurated, sharply demarcated borders. Cellulitis is deeper, involves the subcutaneous connective tissue, and has an indistinct advancing border. Lymphangitis has minimal induration and an unmistakable linear pattern ascending along lymphatic channels. These superficial skin infections are often preceded by minor trauma or the presence of a foreign body, and are most common in patients who have predisposing factors such as diabetes, arterial or venous insufficiency, and lymphatic drainage obstruction. They may be associated with an abscess or they may have no clear-cut origin. With any of these skin infections the patient may have tender lymphadenopathy proximal to the site of infection and may or may not have signs of systemic toxicity (fever, rigors, and listlessness)
What to do:
Look for a possible source of infection and remove it. Debride and cleanse any wound, remove any foreign body or drain any abscess.
When the patient is very sick, or there is discoloration of the entire limb, get medical consultation and prepare for hospitalization. Obtain a CBC and blood cultures and get x rays to look for gas-forming organisms. Hospitalization should also be strongly considered when deep facial cellulitis is present or the patient has a deep i,nfection of the hand.
If there is low-grade fever, or none at all, you can usually treat on an outpatient basis. Prescribe dicloxacillin 500mg qid x 10d, cephalexin 500mg tid x 10d or cefadroxil lgm qd x 10d. Instruct the patient to keep the infected part at rest and elevated and to use intermittent warm moist compresses.
Followup within 24-48 hours to insure that the therapy has been adequate. Infections still worsening after 48 hours of outpatient treatment may require hospital admission for better immobilization, elevation, and intravenous antibiotics.
Discussion
The most common etiologic agents are beta hemolytic streptococci or Staphylococcus aureus. Erysipelas and lymphangitis are often a result of Group A strep alone although S. aureus may produce a similar picture. H. influenzae should be considered in the toxic child with facial cellulitis. It may be easier to evaluate on followup whether a cellulitis is improving or not if the initial margin of redness, swelling, tenderness, or warmth was marked on the skin with a ball point pen. Because response to treatment is often equivocal at 24 hours, reevaluation is usually best scheduled at 48 hours.
Cutaneous Abscess
11.10 Cutaneous Abscess or Pustule
Presentation
With or without a history of minor trauma (such as an embedded foreign body) the patient has localized pain, swelling and redness of the skin. The area is warm, firm, and, usually fluctuant to palpation. There is sometimes surrounding cellulitis or lymphangitis and, in the more serious case, fever. There may be an spot where the abscess is close to the skin, the skin is thinned, and pus may break through to drain spontaneously ("pointing"). A pustule will appear only as a cloudy tender vesicle surrounded by some redness and induration, and occasionally will be the source of an ascending lymphangitis.
What to do:
A pustule may not require any anesthesia for drainage. Simply snip open the cutaneous roof with fine scissors or an inverted #11 blade, grasp an edge with pickups and excise the entire overlying surface. Cleanse the open surface with normal saline and cover it with povidone- iodine ointment and a dressing.
When the location of an abscess cavity is uncertain, attempt to aspirate it with a # 18 gauge needle after prepping the area with povidone-iodine. If an abscess cavity cannot be located, send the patient out on antibiotics and intermittent warm moist compresses and have him seen again in 24 hours.
When the abscess is pointing or has been located by needle aspiration, prepare the overlying skin for incision and drainage with povidone-iodine solution. Anesthetize the area with regional field block, accomplished by injecting a ring of subcutaneous 1% lidocaine solution approximately l cm away from the erythematous border of the abscess. In addition, inject lidocaine into the roof of the abscess along the line of the projected incision.
The incision should be made with a #11 or #15 blade at the most dependent area of fluctuance. It should be large and directed along the relaxed skin tension lines to reduce future scarring
In larger abscesses insert a hemostat into the cavity to break up any loculated collections of pus. The cavity may then be irrigated with normal saline and loosely packed with Iodoform or plain gauze. Leave a small wick of this gauze protruding through the incision to allow for continued drainage and easy removal after 48 hours.
The patient should be instructed to use intermittent warm water soaks or compresses for a few days when there is no packing used or after packing is removed.
A dressing should be provided to collect continued drainage.
What not to do:
Do not incise an abscess that lies in close proximity to a major vessel, such as in the axilla, groin or antecubital space, without first confirming its location and nature by needle aspiration.
Do not treat deep infections of the hands as simple cutaneous abscesses. When significant pain and swelling exists, or there is pain or range of motion of a finger, seek surgical consultation
Discussion
Either trauma or obstruction of glands in the skin can lead to cutaneous abscesses. Incision and drainage is the definitive therapy for these lesions and, therefore, routine cultures and antibiotics are generally not indicated. Exceptions exist in the immunologically suppressed patient, the toxic, febrile patient, or where there is a large area of cellulitis or lymphangitis, in which cases an antibiotic can be selected on the basis of a Gram stain or presumptively based on body location.
It is sometimes not possible to achieve total regional anesthesia for incision and drainage of an abscess, perhaps because local tissue acidosis neutralizes local anesthetics. In such cases, additional analgesia may be obtained by premedication with narcotics or brief inhalation of nitrous oxide.
References:
Llera JL, Levy RC: Treatment of cutaneous abscess: a double-blind clinical study. Ann Emerg Med 1985;14:15-19.
Presentation
With or without a history of minor trauma (such as an embedded foreign body) the patient has localized pain, swelling and redness of the skin. The area is warm, firm, and, usually fluctuant to palpation. There is sometimes surrounding cellulitis or lymphangitis and, in the more serious case, fever. There may be an spot where the abscess is close to the skin, the skin is thinned, and pus may break through to drain spontaneously ("pointing"). A pustule will appear only as a cloudy tender vesicle surrounded by some redness and induration, and occasionally will be the source of an ascending lymphangitis.
What to do:
A pustule may not require any anesthesia for drainage. Simply snip open the cutaneous roof with fine scissors or an inverted #11 blade, grasp an edge with pickups and excise the entire overlying surface. Cleanse the open surface with normal saline and cover it with povidone- iodine ointment and a dressing.
When the location of an abscess cavity is uncertain, attempt to aspirate it with a # 18 gauge needle after prepping the area with povidone-iodine. If an abscess cavity cannot be located, send the patient out on antibiotics and intermittent warm moist compresses and have him seen again in 24 hours.
When the abscess is pointing or has been located by needle aspiration, prepare the overlying skin for incision and drainage with povidone-iodine solution. Anesthetize the area with regional field block, accomplished by injecting a ring of subcutaneous 1% lidocaine solution approximately l cm away from the erythematous border of the abscess. In addition, inject lidocaine into the roof of the abscess along the line of the projected incision.
The incision should be made with a #11 or #15 blade at the most dependent area of fluctuance. It should be large and directed along the relaxed skin tension lines to reduce future scarring
In larger abscesses insert a hemostat into the cavity to break up any loculated collections of pus. The cavity may then be irrigated with normal saline and loosely packed with Iodoform or plain gauze. Leave a small wick of this gauze protruding through the incision to allow for continued drainage and easy removal after 48 hours.
The patient should be instructed to use intermittent warm water soaks or compresses for a few days when there is no packing used or after packing is removed.
A dressing should be provided to collect continued drainage.
What not to do:
Do not incise an abscess that lies in close proximity to a major vessel, such as in the axilla, groin or antecubital space, without first confirming its location and nature by needle aspiration.
Do not treat deep infections of the hands as simple cutaneous abscesses. When significant pain and swelling exists, or there is pain or range of motion of a finger, seek surgical consultation
Discussion
Either trauma or obstruction of glands in the skin can lead to cutaneous abscesses. Incision and drainage is the definitive therapy for these lesions and, therefore, routine cultures and antibiotics are generally not indicated. Exceptions exist in the immunologically suppressed patient, the toxic, febrile patient, or where there is a large area of cellulitis or lymphangitis, in which cases an antibiotic can be selected on the basis of a Gram stain or presumptively based on body location.
It is sometimes not possible to achieve total regional anesthesia for incision and drainage of an abscess, perhaps because local tissue acidosis neutralizes local anesthetics. In such cases, additional analgesia may be obtained by premedication with narcotics or brief inhalation of nitrous oxide.
References:
Llera JL, Levy RC: Treatment of cutaneous abscess: a double-blind clinical study. Ann Emerg Med 1985;14:15-19.
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