Erythema Types in Medicine – Rapid Review For Medical Students

Our skin, the largest organ in the human body, is crucial for maintaining life and overall health. It serves as an airtight, watertight and flexible barrier with the outside world and helps with temperature regulation, immune defense, vitamin production and sensation.

However, the skin is unique in that no other organ demands as much attention in states of disease and health. Our skin’s quality and condition significantly contribute to health, wellness, youth, and beauty perceptions. Such a focus even causes self-esteem and mental health problems stemming from scars, acne, and inflammation to abnormal redness of the skin known as erythema.

Erythema stems from the dilation and irritation of the superficial capillaries and the augmented blood flow that imparts a reddish hue to the skin. Often presenting as a rash, erythema can be caused by environmental factors, infection, or overexposure to the sun.

Since exam season is here, this serves as a rapid review to recall the most common types of Erythema!

Erythema Ab Igne (EAI)

  • The skin reaction stems from chronic exposure to infrared radiation in the form of heat. Once considered a common condition of the elderly who stood or sat closely to open fires or electric space heaters. EAI has reduced significantly with the advent of central heating, although it is still found in individuals exposed to heat from other sources. In EAI, the skin and underlying tissue begin to atrophy, causing patients to complain of mild itchiness and a burning sensation.
  • To prevent the progression of EAI, discontinuing contact with the heat source is necessary.
  •  

Hotbottlerash.JPG
By <a href=”//commons.wikimedia.org/wiki/User:Jmh649″ class=”mw-redirect” title=”User:Jmh649″>James Heilman, MD</a> – <span class=”int-own-work” lang=”en”>Own work</span>, CC BY-SA 3.0, Link

Erythema Chronicum Migrans

  • The primary manifestation of Lyme Disease, erythema chronicum migrans appears 7 to 14 days after the infected tick bite. As an expanding red patch of skin, the size of the rash can reach several centimetres in diameter. The central spot surrounded by clear skin ringed by an expanding red rash known as a bull’s-eye is the most typical appearance.
  • Successful treatment of erythema migrans may be accomplished with 20 days of oral doxycyclineamoxicillin, or cefuroxime axetil.
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Bullseye Lyme Disease Rash.jpg
By Hannah Garrison – <a href=”https://en.wikipedia.org/wiki/User:Jongarrison&#8221; class=”extiw” title=”en:User:Jongarrison”>en:User:Jongarrison</a>, CC BY-SA 2.5, Link

Erythema Induratum

  • Erythema induratum from Bazin disease presents as recurring nodules or lumps on the back of the legs in mostly women that ulcerate and scar.
  • Drugs for treatment include isoniazid, rifampicin, and pyrazinamide, that may be administered orally or intravenously in combination.

An introduction to dermatology (1905) erythema induratum 2.jpg
By Norman Purvis Walker – Walker, Norman Purvis (<span style=”white-space:nowrap”>1905</span>) <a rel=”nofollow” class=”external text” href=”https://books.google.com/books?id=fnYoAAAAYAAJ”>An introduction to dermatology</a> (3rd ed.), William Wood and company Retrieved on 26 September 2010., Public Domain, Link

Erythema Infectiosum or Fifth Disease

  • Erythema infectiosum is also known as the Fifth disease. It is caused by Parvovirus B19 that affects mostly children. The main clinical feature is the “slapped face” appearance along with a sore throat, mild fever and malaise, and signs of Fifth Disease’s prodrome period. The confluent netlike rash begins on the cheeks and spreads to the trunk and extremities.
  • Children may be given NSAIDs to alleviate and relieve fever, headache and achiness.

Fifth disease.jpg
By Andrew Kerr – <span class=”int-own-work” lang=”en”>Own work</span>, Public Domain, Link

Erythema Marginatum

  • Erythema marginatum rheumaticum occurs in about 10% of first attacks of Acute Rheumatic Fever (ARF) in children appearing on their trunk, upper arms and legs as pink or red macules or papules spreading in a circular shape. As the lesions advance, the edges become raised, red, and persist intermittently for weeks to months, even after successful ARF treatment.
  • There is no treatment for erythema marginatum specifically as the rash fades on its own.

Erythema Multiforme

  • Erythema multiforme is a cell-mediated cytotoxic reaction in the skin and mucous membranes triggered by Mycoplasma Pneumoniae or Herpes Simplex Virus or even drugs as sulfonamides, penicillin, barbiturates, NSAIDs, & phenytoin. Vesicles and bullae on the soles, palms, and extensor surfaces with a “targetoid” appearance are characteristic of the rash. Without treatment and care by dermatologists, Steven Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) occur as they are severe forms of erythema multiforme.
  • Treatment includes oral antihistamines, analgesics, local skincare, and soothing mouthwashes.

Erythema multiforme minor of the hand.jpg
By <a href=”//commons.wikimedia.org/wiki/User:Jmh649″ class=”mw-redirect” title=”User:Jmh649″>James Heilman, MD</a> – <span class=”int-own-work” lang=”en”>Own work</span>, CC BY-SA 3.0, Link

Erythema Nodosum

  • Erythema nodosum is an acute inflammatory reaction involving the subcutaneous fat where the skin becomes red, raised and painful on the anterior portions of the shins and wrist. It is more common in women than men, and although the most identifiable cause is streptococcal pharyngitis, it is associated with coccidioidomycosis, histoplasmosis, tuberculosis, leprosy, sarcoidosis, ulcerative colitis, and pregnancy.
  • Anti-inflammatory drugs and corticosteroids by mouth or local injection may serve as treatment options. Colchicine is also administered to reduce inflammation.

ENlegs.JPG
By <a href=”//commons.wikimedia.org/wiki/User:Jmh649″ class=”mw-redirect” title=”User:Jmh649″>James Heilman, MD</a> – <span class=”int-own-work” lang=”en”>Own work</span>, CC BY-SA 3.0, Link

Erythema Toxicum Neonatorum

  • Erythema toxicum neonatorum is a self-limited skin eruption occurring in newborns due to an unknown cause. Erythematous papules, macules and plaques present in all sites except the soles and palms and may last approximately 2-3 weeks.
  • No treatment is necessary for erythema toxicum neonatorum as the lesions regress after 5 days to 2 weeks.

Erythema Elevatum Diutinum (EED)

  • Erythema elevatum diutinum (EED) is a type of necrotising vasculitis characterised by red, purple, or brown papules, plaques, or nodules. It is a rare form of erythema usually found on extensor surfaces overlying the joints, and the buttocks. It is a chronic and progressive skin disease that may last as long as 25 years.
  • The drug of choice for EED is Dapsone because of its rapid onset of action; however, it is possible for lesions to recur the following withdrawal promptly.

Erythema elevatum diutinum on hand.jpg
By <a href=”//commons.wikimedia.org/w/index.php?title=User:Dswierc&amp;action=edit&amp;redlink=1″ class=”new” title=”User:Dswierc (page does not exist)”>D Swierczek</a> – <span class=”int-own-work” lang=”en”>Own work</span>, CC BY-SA 4.0, Link

Erythema Gyratum Repens

  • Erythema gyratum repens is a rare paraneoplastic type of annular erythema with a ‘wood-grain’ appearance associated with malignancy. Furthermore, almost half of the patients with erythema gyratum repens have lung cancer and less commonly, oesophageal, breast, and stomach cancer.
  • The rash usually resolves once the malignancy has been removed with surgical resection.

References and Further Reading

Cite this article as: Leah Sarah Peer, Canada, "Erythema Types in Medicine – Rapid Review For Medical Students," in International Emergency Medicine Education Project, January 4, 2021, https://iem-student.org/2021/01/04/erythema-review-for-medical-students/, date accessed: October 18, 2021

Suicide – An Emergency Priority of Public Health Care

Suicide An Emergency

A significant number of emergency department visits annually arise as a result of intentional self-harm. Although no accurate description explains what leads to suicide or what comes after, it is a multifaceted phenomenon of public health urgency during a global health crisis. In the United States alone, suicide is the 10th leading cause of death and worldwide claims up to 800,000 lives each year. The international community must unite to come up with solutions to prevent the loss of life, as every single life lost is one too many.

With the COVID-19 pandemic, such an emergency naturally affects both individuals’ health and well-being and the communities in which they live. Unprecedented times unleash various emotional reactions from isolation, grief and trauma to other unhealthy behaviours, noncompliance with public health guidelines and the exacerbation of mental health conditions. While those who’ve been emotionally, sexually or physically abused in the past are more vulnerable to the psychosocial effects of a crisis, supportive interventions such as the Zero Suicide program and Cognitive Behavioural Therapy designed to promote wellness and enhance coping should be implemented [1]. 

In honour of World Suicide Prevention Week, and World Suicide Prevention Day held on the 10th of September every year, it is important to raise attention to the global importance of suicide prevention. Suicide impacts all people and particularly the world’s most marginalized and discriminated groups. It is a huge problem in developed countries and just as serious in low-and middle income countries where resources and access to healthcare professionals are scarce. In many regions of the world, the taboo and stigma surrounding suicide persist, causing people in need of help to be left alone. 

Suicide prevention with awareness campaigns ought to be prioritized on the global health and public policy agendas as a major public health issue. Routine screening for suicidal ideation by health care professionals providing care should identify and assess suicide risk among populations. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), risk factors of suicide include mental illness, substance use diagnoses, trauma or conflict, loss, family history of suicide, and previous suicide attempts [2].

Effectively implementing suicide prevention strategies at the populational, sub-populational and individual level requires ensuring patients’ lethal means are restricted, reduced, and that all accesss to weapons of self-harm are removed from the nearby environments. Healthcare providers should keep up to date with new developments, research, and technologies screening for suicidal ideation, allowing them to effectively serve patients beyond their clinics’ walls. Key to prevention are strong physician patient relationships that help ensure care transitions allow for physicians to act as supportive contacts reaching out with calls, texts, letters and visits to their patients particularly when services are interrupted. With access to technology the role of psychiatrists, and psychologists may continue uninterrupted as telemedicine serves as an effective platform providing patients with access to care, even during lockdowns. Besides these objectives, greater awareness and education into the community means encouraging the responsible portrayal of suicide in mainstream media. A sensitive issue of this magnitude ought to be communicated responsibly placing special attention to not trigger susceptible individuals. With school based interventions, professionals may act sooner before worsened prognosis’ effectively ensuring that access to peer support services is available. 

Suicide prevention is a responsibility of healthcare systems, medical professionals and communities. All countries must stand in solidarity and unify in collaboration to battle this common threat as preventing the tragic loss of life to suicide is of utmost importance. 

References & Further Reading

  1. In Health and Behavioral Healthcare. (n.d.). Retrieved September 14, 2020, from http://zerosuicide.edc.org/toolkit/treat/interventions-suicide-risk 
  2. Psychiatry Online: DSM Library. (n.d.). Retrieved September 15, 2020, from https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596 
Cite this article as: Leah Sarah Peer, Canada, "Suicide – An Emergency Priority of Public Health Care," in International Emergency Medicine Education Project, October 19, 2020, https://iem-student.org/2020/10/19/suicide-an-emergency-priority-of-public-health-care/, date accessed: October 18, 2021

The Kawasaki Disease Enigma Continues 150 years Later

kawasaki disease

Kawasaki disease (KD), or mucocutaneous lymph nodes syndrome is an immune-mediated inflammation in the walls of medium-sized arteries throughout the body. It’s complications result in the coronary arteries expanding, heart attacks, and premature death.

As the leading cause of heart disease in North American and Japanese children, KD continues to bewilder clinicians and researchers – even in the midst of a global pandemic. Possible links to SARS-CoV2 has even stirred uneasiness in patients, and physicians making diagnoses.

Beginning in Victorian-era England, a young boy presented to the doctor’s office with symptoms suggestive of scarlet fever; however, noticing heart disease in this child was just baffling. Despite being unaware of this rare disease, it was beyond physicians at the time; since then, progress has been limited as clinicians still fail to comprehend the disease’s root cause.

Dating back to 1874, KD was discovered by Samuel Gee while he was dissecting the cadaver of a seven-year-old boy.

He noticed something strange, “The pericardium was natural. The heart natural in size, and the valves healthy. The coronary arteries were dilated into aneurysms at three places, namely, at the apex of the heart a small aneurysm the size of a pea; at the base of the right ventricle, close to the tip of the right auricular appendix, and near to the mouth of one of the coronary arteries, another aneurysm of the same size; and at the back of the heart, at the base of the ventricles, and in the sulcus between the ventricles, a third aneurysm the size of a horse bean. These aneurysms contained small recent clots, quite loose. The aorta near the valves, and the aortic cusp of the mitral valve, presented specks of atheroma.

From his autopsy, evident was that Gee found aneurysms in the coronary arteries running across the surface of the boy’s heart. He then placed the specimen in a jar and provided it to the Barts Pathology Museum in London. Little did he know, that his specimen marked evidence of the earliest recorded case of KD and sparked worldwide medical curiosity. Unfortunately, when physicians 100 years later were hoping to retrieve samples from the specimen containing the boy’s heart, they were informed that it was missing.

A few years later, the disease was recognized in 1967 by the Japanese physician, Tomikasu Kawasaki. Although some researchers claimed the virus was unknown, others stated KD resulted from a bacterial or fungal toxin. The windborne theory suggested that the disease was seasonal, and as such, the direction of the swaying wind played a role in infection. Others stated that since children’s immune systems are still developing and since they have just lost the protective antibodies from their mothers, they are susceptible to infection. Therefore, in Asian American household’s diets rich in soy put Asian children at greater risk due to the isoflavones. In the 1980s, the Center for Disease Control and Prevention (CDC) suspected chemicals as the cause of KD, inferring that disease stems from agents that trigger an overreaction of the patient’s immune system. No one knew exactly what the mechanism or cause of KD was, although many scientists speculated some theories.

Over the last decade, significant progress toward understanding the pathogenesis, history, and therapeutic interventions of KD has been fruitful. Treatment aimed at the intravenous infusion of gamma globulin antibodies derived from the plasma of blood donations has helped children recover. In contrast, other therapies of corticosteroids for immunoglobulin-resistant patients and tumor inhibitors such as etanercept, infliximab, and cyclosporin A have been other medications providing relief.

The most significant clinical debate was over the possible link between the rash and the cardiac complications seen in Asian American children. Factors responsible for KD were introduced into Japan after World War II and re-emerged in a more virulent form spreading through the industrialized Western world. Advancements in medicine, improvements in healthcare, and, notably, the use of antibiotics reduced the burden of rash and fever illnesses significantly allowing KD to be recognized as a distinct clinical entity.

Nonetheless, the enigma pervades even during the COVID19 pandemic; this time, more pressing as the ever-elusive cause of KD that troubles children’s hearts affects physicians’ sleep and worries parents’ minds. Although the story of Kawasaki disease began decades ago when a young boy’s heart was locked inside a glass specimen, its ending is still being crafted. By the time the heart is found again at the museum, and placed safely for visitors treasuring ancient history, what further knowledge and progress will the scientific community have achieved? How far will humanity have come to find answers to KD and fill in the perplexing missing piece of the puzzle?

For now, there are no answers, but the enigma continues…

Cite this article as: Leah Sarah Peer, Canada, "The Kawasaki Disease Enigma Continues 150 years Later," in International Emergency Medicine Education Project, July 24, 2020, https://iem-student.org/2020/07/24/kawasaki-disease-enigma-continues/, date accessed: October 18, 2021

References and Further Reading

A Lens Beyond Emergency Medicine

A lens beyond emergency medicine

The emergency room constantly presents challenges, and physicians always have to act with urgency. Patients, on the other hand, fear diagnoses they will hear, being unprepared to deal with the consequences, let alone mustering the strength to inform their loved ones. In this chaotic and busy environment of the emergency department, healthcare professionals often overlook a core value: to facilitate healing beyond medicine.

Physicians strive to express compassion when faced with life and death matters, but doctors are human too! They suffer from many emotions their patients go through, sometimes more than their hearts can contain. On top of that, they are expected to provide care continuously, so they may reach a threshold where dying patients and crying family members seem to not affect them. The danger is physicians’ becoming “machines” lacking human emotions, consideration or care.

The importance of not losing our humanity cannot be overemphasized. Physicians are not only healthcare providers but they are leaders and health advocates. When conventional medicine fails to provide treatment, physicians have a responsibility to assure patients that they will be with them every step of the way. We are responsible for our patients’ lives from the day we take care of them. Let’s not mistake this for disregarding patient autonomy. Patients are entitled to decide for themselves, but a caring practitioner -one that listens and engages in conversation- will make the difference. Our responsibility is to make patients feel empowered. We can make a clinical difference by touching our patients beyond the physical.

Physicians must expand their perspective to see beyond emergency medicine. Conventional medicine has taught us to observe the patient for signs and symptoms but deemphasized patients’ expressions, feelings, ambitions, and dreams. Why should we see patients from just one lens? Medical students, physicians, and other healthcare professionals in the emergency department should remind themselves of perceiving a more subjective but meaningful aspect of patient care, which lies beyond the physical. True healing requires a multidisciplinary effort, including familial, environmental, and socio-economical aspects of care.

Social aspects of medicine play a crucial role and should never be neglected. Our utmost responsibility is to foster solidarity, peace, and humaneness in this world. Compassion must be the center of our every action as we concentrate on understanding the patient as a human, rather than the diseases. Physicians that mind the interconnections between medicine, emotions, and humans, make a difference.

Cite this article as: Leah Sarah Peer, Canada, "A Lens Beyond Emergency Medicine," in International Emergency Medicine Education Project, April 10, 2020, https://iem-student.org/2020/04/10/a-lens-beyond-emergency-medicine/, date accessed: October 18, 2021