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Chapter 249: Generalized Skin Disorders

William J. Brady; Amit Anil Kumar Pandit; Mark R. Sochor

INTRODUCTION

This chapter describes selected serious generalized skin disorders in adults and discusses their dermatologic diagnosis and treatment. Covered are erythema multiforme, toxic epidermal necrolysis, exfoliative erythroderma, the toxic infectious erythemas, disseminated viral infections, Rocky Mountain spotted fever, disseminated gonococcal infection, purpura fulminans, and pemphigus vulgaris. Staphylococcal scalded skin syndrome and meningococcemia are discussed in the pediatric section, in Chapter 142, “Rashes in Infants and Children.” Disseminated viral infections are discussed in Chapter 154, “Serious Viral Infections” and in Chapter 142.

The disorders erythema multiforme, toxic epidermal necrolysis, exfoliative erythroderma, staphylococcal and streptococcal toxic shock syndrome, and staphylococcal scalded skin syndrome share some features in common. Table 249-1 can help to differentiate these disorders. Management is summarized in Table 249-2.

TABLE 249-1Comparison of Inflammatory and Infectious Generalized Skin Disorders
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TABLE 249-1 Comparison of Inflammatory and Infectious Generalized Skin Disorders
Disorder Appearance Special Features
Erythema multiforme

Erythematous macules, papules

Target lesions

Urticaria or vesiculobullous lesions

Cutaneous reaction to drugs or infectious agents.

Stevens-Johnson syndrome is the most severe form.
Toxic epidermal necrosis

Painful, tender erythroderma

Vesicles and bullae

Exfoliation

Nikolsky sign present.

Stevens-Johnson syndrome is most severe form.

Drugs most common cause.
Exfoliative erythroderma

Nontender erythema

Skin flaking and scaling

Thickening of skin

 Often preexisting eczema or psoriasis; can be drug induced.
Staphylococcal or streptococcal toxic shock syndrome

Staphylococcal: fine punctate erythematous lesions that become confluent; blanching erythroderma; desquamation first of trunk and face, then extremities

Streptococcal: can be indistinguishable from staphylococcal toxic shock; scarlatiniform erythroderma with sheet-like desquamation of skin

Colonization or infection with Staphylococcus aureus; menstruation associated with tampon use; nonmenstrual associated with burns, cellulites, sinusitis, wounds, etc.

Group A streptococcal cellulitis, puerperal sepsis, any group A β-hemolytic Streptococcus infection source.
Staphylococcal scalded skin syndrome

Scarlatiniform rash or erythema

Bullae or bullous impetigo

Sloughing of skin

Usually seen in neonates or children <5 y of age.

Nikolsky sign present.
TABLE 249-2Management of Serious Generalized Skin Disorders
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TABLE 249-2 Management of Serious Generalized Skin Disorders
Disorder Treatment Disposition/Comments
Erythema multiforme minor

  • Steroid (prednisone 60–80 milligrams PO daily for 3–5 d or equivalent)

  • Oral antihistamine (diphenhydramine 25–50 milligrams every 4–6 h or equivalent)

  • Acyclovir for herpes simplex virus–related event (recurrence suppression only)

  • Remove trigger if identified

  • Outpatient management

  • Primary care physician or dermatology follow-up
Erythema multiforme major (Stevens-Johnson syndrome)

  • Resuscitate as needed (respiratory +/– circulatory)

  • Fluid and electrolyte management as needed

  • Steroid (as above or methylprednisolone 125 milligrams IV every 6 h or equivalent)*

  • Pain management as appropriate

  • Diphenhydramine and viscous lidocaine rinses for oral lesions

  • Burow’s solution (5% aluminum acetate) with cool compresses for blisters

  • Ophthalmologist for ocular lesions

  • Antibiotic only for suspected or established infection (i.e., not prophylactic)

  • Remove trigger if identified

  • Inpatient management; acute, critical care, or burn unit

  • Intensivist† and dermatologist consultations
Toxic epidermal ...

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