Evaluation of select dermatologic Emergencies in the ED
Laboratory studies for dermatology emergencies generally include CBCD and CMP. Blood and urine cultures should be obtained when patient is febrile and/or with unstable vital signs.
Suspected Diagnosis | Presentation | Initial Management | Specific labs/workup |
DRESS/DIHS (Drug reaction with eosinophilia and systemic symptoms (DRESS)/Drug Induced Hypersensitivity Syndrome | Morbilliform cutaneous eruption with facial edema, fever, LAD in setting of exposure to anti-epileptics and antibiotics within 2-6 weeks after exposure | Hold potential offending medication
Supportive care, IVF | - CBCD with blood smear, CMP, UA with micro - Chest X ray if pulmonary symptoms - ECHO if cardiac symptoms |
SJS/TEN
| Erosions of two mucosal sites (conjunctiva, oropharynx, genital mucosa) as well as targetoid cutaneous eruption with extensive skin rash/peeling > 10% BSA in setting of medication exposure (most commonly antibiotics, anticonvulsants, or NSAIDs)
| Hold potential offending medication
Supportive care, IVF
| - CBCD, CMP, UA with micro, ESR, CRP - If viral symptoms- check RVP and mycoplasma titers
|
MRIM/RIME (Reactive Infectious Mucocutaneous Eruption) | Prominent mucositis, often conjunctivitis, limited or absent skin involvement, often following viral or bacterial infection, absence of medication exposure | Supportive care, IVF
| - CBCD, CMP - If viral symptoms- check RVP and mycoplasma titers - If cough, check chest X-ray |
Staphylococcal Scalded Skin Syndrome
| Presentation typically perioral radial fissuring, erythema in flexures with superficial peeling, fevers
| If febrile, unable to take adequate hydration, or severe skin involvement, inpatient admission appropriate for management, first line therapy a penicillinase-resistant, anti-staphylococcal antibiotic
| -CBCD, CMP, ESR, CRP, blood and urine cultures -Skin cultures from nares, umbilicus, perianal area, and any obviously crusted site
|
Erythroderma (> 90% total body surface area)
|
| If associated fevers or signs of sepsis, obtain blood and urine cultures, skin cultures from any obvious infected sites, consider empiric anti-staph coverage
| CBCD, CMP, blood and urine cultures |
Evaluation of non-urgent Dermatologic Conditions (PCP needs to place outpatient referral if needed)
Condition | Initial Management | Special Considerations |
Warts/Verruca | Advise OTC salicylic acid
| Consider social work if genital and > 5 years of age |
Molluscum | Supportive care, pain control | Can get inflamed, does not get secondarily infected |
Atopic dermatitis Flare | Initiate hydrocortisone 2.5% ointment for face/neck BID and triamcinolone 0.1% ointment for body BID. If severe, advise wet wraps.
| Skin culture if clinical evidence of heavy impetiginization Empiric cephalexin if evidence of severe impetiginization or cellulitis |
Hidradenitis Supprativa (known diagnosis with flare) | Consider simple I&D if abscess present, send fluid for culture, do not pack site, pain control, consider short (30 day course) of doxycycline 100 mg PO BID while awaiting outpatient derm evaluation/follow-up
| If diagnosis not established, should rule out abscess |
Bullous Impetigo | Obtain skin culture; if localized to one body area and afebrile consider topical antibiotics; if widespread and systemic symptoms -> oral or IV antibiotics for MSSA, obtain skin culture
|
|
Acute Annular Urticaria | Inquire about recent exposures (new foods, viral symptoms, medications), supportive care with oral antihistamines | Atypical urticaria lesions lasts longer than 24 hours, leave behind discoloration, have pain instead of itch |
Serum Sickness-like reaction | Urticarial reaction (to be distinguished from true serum sickness which is type III hypersensitivity reaction), often lacy urticarial plaques, may have fever, arthralgias, and recent viral symptoms or medication exposure | Inquire about recent exposures (new foods, viral symptoms, medications)
|
Diaper Dermatitis | Often multifactorial, differential to consider includes irritant contact dermatitis, impetigo, perianal strep, candida, Jacquet’s erosive dermatitis | Consider cultures for secondary infection (bacterial, candidal) if suspected |
Developed by: R. Ahmad (Derm)
Reviewed by: Bin, Daftary (PEM)
Posted: 7/2025
Version: 1.0
Keywords: Dermatology, CMCD, CMP