Dermatological trends in emergency medicine.

BACKGROUND: Trends in emergency department (ED) visits with a primary dermatologic diagnosis are not well characterized. OBJECTIVE: The goal is to determine how the number of ED visits attributable to dermatologic disease is changing and to characterize the type of dermatologic conditions seen. METHODS: This is a cross-sectional study using the National Hospital Ambulatory Medical Care Survey: Emergency Department Summary Tables 2008-2017. Data were compiled into tables on the amount and type of dermatologic ED visits. RESULTS: The percentage of dermatologic visits ranged from an estimated 3.5% to 4.3%, peaking in 2014. Cellulitis was the most common diagnosis and accounted for an estimated 1.3% of all visits in 2016, and an estimated 1.2% of visits in 2017. The second most common diagnosis was cutaneous abscess, which accounted for an estimated 0.8% in 2016 and 0.9% in 2017. CONCLUSION: The number of ED visits attributed to disease of the skin and subcutaneous tissue has not followed a general trend of increase or decrease. The most common diagnoses are infections. We can best serve these patients by emphasizing the importance of ED provider education on the management of cutaneous infections and by working to increase the accessibility of dermatologic care.

Erythema nodosum and pernicious anemia.

Erythema nodosum (EN) often presents as a sudden onset of tender, erythematous, subcutaneous nodules on the legs and ankles. Although rare, pernicious anemia may be related to vitamin B12 deficiency. Discussion of this association in the context of a particular patient is presented.

Idiopathic granulomatous lobular mastitis.

Idiopathic granulomatous lobular mastitis (IGLM) is a rare breast condition with prominent skin findings. It is typically seen in young parous women. Painful breast masses, draining sinuses, scarring, and breast atrophy are the main clinical manifestations. IGLM can resemble a variety of other inflammatory and neoplastic processes of the breast. It is thought to result from obstruction and rupture of breast lobules. Extravasated breast secretions then induce an inflammatory reaction. Corynebacteria have also been implicated in the pathogenesis. Treatment is surgical, but systemic corticosteroids, methotrexate, and antibiotics also play a role.

Superantigens in dermatology.

Superantigens (SAgs) are virulent polypeptides that are produced by a variety of infectious organisms. They are capable of causing nonspecific T cell activation by circumventing normal antigen processing in the human host. The genetic makeup of the host plays a role in conferring susceptibility or protection against SAgs. They are linked to a variety of conditions, ranging from toxic shock syndrome to recurrent toxin-mediated perineal erythema. The early recognition of signs and symptoms of SAg-mediated illnesses is important to ensure prompt medical treatment.

Toxic epidermal necrolysis.

UNLABELLED: Toxic epidermal necrolysis (TEN) is an unpredictable, life-threatening drug reaction associated with a 30% mortality. Massive keratinocyte apoptosis is the hallmark of TEN. Cytotoxic T lymphocytes appear to be the main effector cells and there is experimental evidence for involvement of both the Fas-Fas ligand and perforin/granzyme pathways. Optimal treatment for these patients remains to be clarified. Discontinuation of the offending drug and prompt referral to a burn unit are generally agreed upon steps. Beyond that, however, considerable controversy exists. Evidence both pro and con exists for the use of IVIG, systemic corticosteroid, and other measures. There is also evidence suggesting that combination therapies may be of value. All the clinical data, however, is anecdotal or based on observational or retrospective studies. Definitive answers are not yet available. Given the rarity of TEN and the large number of patients required for a study to be statistically meaningful, placebo controlled trials are logistically difficult to accomplish. The absence of an animal model further hampers research into this condition. This article reviews recent data concerning clinical presentation, pathogenesis and treatment of TEN. LEARNING OBJECTIVES: At the conclusion of this learning activity, participants should have acquired a more comprehensive knowledge of our current understanding of the classification, clinical presentation, etiology, pathophysiology, prognosis, and treatment of TEN.