Inpatient teledermatology service: baseline review - it works!

Setting up an inpatient teledermatology service over 1 year at our National Health Service-based district general hospital made absolute sense on two grounds: The COVID pandemic and the ever-increasing role of teledermatology enabling dermatology departments, often with limited resources, to 'work smart'. Over a 43-week period, 124 referrals were dealt with on our teledermatology platform (around 12 referrals per month). Average response time to referral was 0.65 days: 56% same-day response, 32% next-day response;and 92% a response within 3 days. Following this, 32% of patients were seen face to face on the wards and 40% were dealt with via remote advice and guidance. Around 10% of referrals were deemed not to be appropriate for dermatology review/advice. Around 12% of referrals were given dermatology face-to-face outpatient appointments rather than review on the wards, and 7% were declined an appointment (pending further information being received) as insufficient information was given for triage/advice and guidance. Initially, just 10% of referrals were sent (first time) with clinical images, but this increased to 54% after 4 months, and although there has been some monthly variation, up to 64% has been achieved (noting that clinical images are not always required for the question being asked). Around 50 different diagnoses were made, illustrating the diversity and complexity of dermatological practice, and the scale of the diagnostic problems facing ward-based teams. Previously published data revealed that around one-third of inpatient dermatology referrals were for 'red legs', which was replicated in the current results, with diagnoses of venous or atopic eczema (14%), drug reactions (12%), skin neoplasia (6%), cellulitis/erysipelas (5%), intertrigo (4%), erythroderma (4%), Gianotti-Crosti syndrome (2.5%), bullous pemphigoid (2.5%), pyoderma gangrenosum (2.5%) and vasculitis (2%). Having an inpatient teledermatology service benefits dermatology departments, enabling efficient working, appropriate triage, training opportunities and ease of second opinions from colleagues. Benefits for referrers are acute ward-based teams including rapid responses to referrals, enabling skin concerns to be dealt with quickly and avoiding delays in investigation, treatment and discharge. Some hospitals where dermatology does not have a permanent base may be able to access dermatology advice and guidance via teledermatology. Overall, patients benefit from teledermatology and it is COVID secure.

Clinico-Epidemiological Profile of Cutaneous Adverse Drug Reactions at Rural Tertiary Care Centre

Background: Cutaneous adverse drug reactions (CADRs), also known as toxidermia, are skin manifestations resulting from systemic drug administration and it constituted 10%-30% among all reported adverse drug reactions (ADRs). These reactions range from mild morbilliform drug rash to much more severe reactions. Material(s) and Method(s): A retrospective observational study was conducted at dermatology outpatient department of rural based tertiary care center for a duration of 03 years from August 2019 to July 2022, a total of 211 patients who had been clinically diagnosed or were suspected to have drug reactions were studied. Result(s): In this observation there was male preponderance (59.72%) and majority of patients were in their 3rd and 4th decade (40.28%) with maculopapular drug rash (33.17%) being most common clinical profile of CADRs, followed by urticaria (23.70%). Less frequently seen CADRs were acneiform eruptions (21), hair Loss (9), photodermatitis (9), generalised pruritus (7), erythroderma (2), pityriasis rosea (2), Stevens Johnson Syndrome-Toxic Epidermal Necrolysis (SJS-TEN) (4), lichenoid drug eruptions (3), Vasculitis (1) and pustular drug eruption (1). The most common group of drugs causing CADRs were antibiotics (40.28%), followed by NSAIDs (28.43%). Conclusion(s): Cutaneous Adverse Drug Reactions (CADRs) are price we pay for the benefits of modern drug therapy;knowledge of these reactions is important for treating physician as prompt recognition and treatment can prove lifesaving.Copyright © 2022 Academic Medicine and Pharmacy

Erythroderma and Eosinophilia with Multi-System Involvement, a Case of Vress

Introduction: Resembling Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS), Virus Reactivation with Eosinophilia and Systemic Symptoms (VRESS) occurs triggered by members of Herpesviridae family viruses. Case Description: A 12-year-old male was hospitalized with a 5-day history of fever, pruritic erythematous rash on the trunk and extremities, and facial edema. The patient was exposed to a cousin diagnosed with Multisystem Inflammatory Syndrome in Children (MIS-C) 10 days prior. No history of traveling, unusual food intake, URI, drug ingestion during the prior 3 months. Patient was treated with clindamycin x 10 days for possible Staphylococcal Scalded Skin Syndrome. Patient was noted to have eosinophilia of >2000 that persisted through the hospital course and thereafter, transaminitis with direct bilirubinemia, transient microscopic hematuria, elevated CRP and C3, normal EKG and chest radiograph, normal T/B/NKC counts, normal levels of immunoglobulins and elevated IgE (2163>1579IU/mL). IgG and IgM were negative for: CMV, adenovirus, strongyloidces, HAV, HBV, and HIV. IgG positive to: EBV, HHV-6, mycoplasma, HHV-6, HSV1, and parvovirus. Negative cultures for MRSA and group A Streptococcus. Negative PCRs for COVID -19. At 8 week follow up, skin erythema evolved into desquamation in the fingers and eosinophilia persisted. Discussion(s): VRESS should be on the differential for patients presenting with a DRESS-like symptoms in the absence of drug exposures. VRESS is often triggered by members of the Herpesviridae family of viruses including EBV and HHV-6, to both of which this patient was exposed to in the past. While diagnosis is one of exclusion, early identification can guide appropriate management. Copyright © 2022

Generalized exanthem as a presenting symptom of COVID-19

Coronavirus disease 2019 (COVID-19) has many cutaneous manifestations. We describe a 30-year-old otherwise healthy male with a generalized purpuric exanthem. Ten days after the onset of the rash, he presented with fatigue, dry cough, shortness of breath, anosmia, and ageusia and was diagnosed as having COVID-19. The presence of an extensive exanthem in an otherwise healthy patient could raise suspicion for underlying COVID-19.

Erythrodermic flare-up of psoriasis with COVID-19 infection: A report of two cases and a comprehensive review of literature focusing on the mutual effect of psoriasis and COVID-19 on each other along with the special challenges of the pandemic.

The COVID-19 pandemic has been extra challenging for patients with chronic diseases. Psoriasis is one of the chronic conditions that its treatment mostly relies on immunosuppressants. In this study, we report two cases with a long history of psoriasis that COVID-19 infection caused them to undergo erythrodermic psoriasis.

A case of severe psoriatic erythroderma with COVID-19.

COVID-19 caused by the SARS-CoV-2, became pandemic very quickly. Management of severe dermatologic disorders in patients who require systemic immunosuppressive treatment is a major concern in COVID-19 pandemic era. Here, we report a 45-year-old homeless addicted male with second flare of psoriatic erythroderma and positive PCR test for COVID 19. His first attack occurred two months earlier, when he was screened for SARS-CoV-2 before admission which all evaluations showed nagative results. The patient was treated and relatively controlled with cyclosporine and therefore he was discharged. During this interval, he not only discontinued his medication, but also became SARS-CoV-2 positive. It seems that both factors participated in flare of his erythroderma.