- Normal saline, IV,
Reactive Erythema and Bullous Reaction
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These are immunologic reactions characterized by reddening with or without blistering of the skin and/or mucosa. The common types are erythema multiforme, Stevens-Johnson syndrome and toxic epidermal necrolysis (TEN). With all these conditions, there could be accompanying extensive denudation of skin with consequent fluid and electrolyte loss and a risk of secondary bacterial infection. All three conditions should be considered as emergencies requiring intensive care.
Erythema multiforme presents as itchy, target-like, non-scaly lesions of the palms, soles, forearms and legs.
Stevens-Johnson syndrome is characterized by erythema and blister formation, which additionally involves the mucous membranes (conjunctiva, mouth, genitals etc.).
Toxic epidermal necrolysis (TEN) is a generalized scalded type of skin reaction, often due to an allergic reaction to drugs. A similar reaction occurs in children termed staphylococcal scalded skin syndrome, which is caused by Staphylococcus aureus.
Cause
- Viral infections e.g. herpes simplex virus, retrovirus, cytomegalovirus
- Mycoplasma pnuemoniae infection
- Adverse drug reaction e.g. to sulphonamides, penicillin, NSAIDS, anticonvulsants etc.
- Malignancy
Symptoms
- Fever
- Blisters
- Itchy rash
- Sore throat
- General malaise
- Discharging painful eyes
- Asymptomatic
Signs
- Fever
- Flaccid bullae
- Genital and/or oral ulcerations
- Denuded area of skin
Investigations
- FBC
- BUE & creatinine
- HIV screen
- Blood and wound cultures (if indicated)
TreatmentTreatment Objectives
- To maintain adequate hydration
- To maintain adequate nutrition
- To correct electrolyte imbalance
- To maintain normal body temperature
- To prevent secondary infection
- To identify and eliminate underlying cause
- To prevent further exposure to the causative agent or drug
Non-pharmacological treatment
- Withdrawal of identifiable causative agent or drug
- Maintenance of adequate input and output of fluid
- Adequate oral fluids
- Prevent contact of ulcerated skin with contaminated linen using a nursing cradle
- Early ophthalmological consultation
- Nutritious diet
Pharmacological treatment
Referral CriteriaRefer all patients to appropriate specialist.
Evidence Rating: [A]
- Paracetamol, oral,
Adults
500 mg-1 g 6-8 hourly
Children
6-12 years; 250-500 mg 6-8 hourly
1-5 years; 120-250 mg 6-8 hourly
3 months-1 year; 60-120 mg 6-8 hourly
Evidence Rating: [C]
- Prednisolone, oral, (at onset of condition)
Adults
0.5-1 mg/kg daily and taper off over 7-10 days
Children
0.5 mg/kg daily and taper off over 7-10 days
- Hydrocortisone, IV,
Adults
100 mg 6 hourly until able to swallow
Then
- Prednisolone, oral, as above
Children
4 mg/kg 6 hourly until able to swallow
Then
- Prednisolone, oral, as above
Evidence Rating: [B]
- Azithromycin, oral,
Adults
500 mg daily for 5 days
Children
10 mg/kg once daily for 5 days
< 6 months; not recommended
Or
- Erythromycin, oral,
Adults
500 mg 6 hourly for 7 days
Children
6-12 years; 250 mg 6 hourly for 7 days
1-5 years; 125 mg 6 hourly for 7 days
< 1 year; 62.5 mg 6 hourly for 7 days
Evidence Rating: [C]
- Chlorhexidine solution 4%, topical,
Or
- Cetrimide 15%, topical,
Or
- Povidone iodine solution 10%, topical
Note: Do not use silver sulfadiazine as it is a sulfa drug for skin care
- Povidone iodine 1% mouthwash, 12 hourly
Or
- Chlorhexidine 0.12% mouthwash, 12 hourly