Do Not Miss Skin Lesions

Sir, If you miss, the patient might not live, such is the fate of certain patients who present with nothing but a minor skin eruption or lesion and often go undiagnosed. The knowledge of certain telltale lesions will prevent patients from landing in the intensive care unit. Steven–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are two extremes of an exfoliating skin disorder. It can be life-threatening; it presents with fever and malaise and upper respiratory tract symptoms, and then, over the next 3–4 days, it progresses into a blistering skin rash and erosions appear all over the body and on the mucosal surfaces. The clinical manifestations are targetoid or annular macules, flaccid bullae, and a positive Nikolsky’s sign.[1] The targetoid lesion sin erythema multiforme major are (EMM) are raised but lesions in SJS are flat and atypical and involve mostly three mucosal sites namely conjunctiva, oral mucosa and genitourinary tract. SJS involves <10% of the body surface area, whereas TEN involves >30%.[1] Sulfonamides, allopurinol, and anticonvulsants are drugs to watch out for. Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome is a life-threatening idiosyncratic drug reaction that has a long latency since the onset of the drug about 2–8 weeks. It starts as fever, rash, eosinophilia, leukocytosis, and abnormal liver function tests, which can mimic viral hepatitis. The cutaneous manifestations typically consist of an urticarial, maculopapular eruption, cheilitis, and erythroderma.[2] The onset between drug and SJS/TEN is <4 weeks, but for DRESS, it’s longer. Staphylococcal skin scalded syndrome is a predominantly childhood blistering severe skin disease mostly below 6 years of age. It is due to the epidermolytic toxin of Staphylococcus aureus. It presents as characteristic blisters in localized or diffused areas, and it ruptures denuding the skin having positive Nikolsky’s sign. There is a focus of infection, and the skin is affected by tender, perioral crusting which when peeled leaves behind radial scars that are the characteristic facies of this disease.[3] Here, only the epidermis is denuded. The target lesions appearing when infected with Mycoplasma Pneumoniae, Ebstein Barr Virus and Herpes Simplex Virus I and II measure < 3cm , and their location is mainly acral and symmetrical.[4] Next is purpura fulminans, a life-threatening dermatological emergency; here, the skin manifestation is just like warfarin-induced skin necrosis. It presents with fever, hemorrhage, hypotension, and eventually disseminated intravascular coagulation and circulatory collapse. The skin manifestation starts with erythema followed by irregular central areas of blue-black hemorrhagic necrosis with vesicles and bulla; the skin is intensely painful with eventual loss of sensation. Warfarin-induced skin necrosis is just skin necrosis within 48–72 h of starting the drug, due to microvascular thrombi.[5] Disseminated gonococcal infection, a fatal disease, is a clear early indicator of this outcome; there is a nonpruritic painless maculopapular rash followed by scattered petechiae and vesicular–pustular painful lesions. Tenosynovitis and other features are fairly late sequelae of this. In addition to the above, there are many other lesions and dermatological manifestations of underlying diseases, but the above are the important ones. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.