Life Threatening Skin Rash series – Toxic Shock Syndrome

Toxic shock syndrome eczema

Picture taken from http://www.healthline.com/health/toxic-shock-syndrome#Overview1

Toxic shock syndrome is rare but life threatening, caused by bacterial toxins from staphylococcus aureus. Toxic Shock Syndrome commonly affects teens and young adults, from age 15 to 35 and majority, female.

What Causes Toxic Shock Syndrome?

Toxic Shock Syndrome is due the bacterial infection via the skin, vagina or pharynx into the bloodstream. While it is not uncommon for Staph bacteria to colonize the skin, a cut, surgery or wound in some individuals may lead to the bacteria entering the blood without immunity to fight it. The conducive environment for the toxin is protein-rich and oxygen, which is what the use of tampons during menstruation provides. Tampons with higher absorbency (polyester, carboxymethylcellulose and polyacrylate) increases the risk of TSS. The toxins can cross the vaginal wall to the blood stream, possibly through tear when inserting the tampon.

Symptoms of Toxic Shock Syndrome

  • Flu-like symptoms
  • Confusion, dizziness due to low blood pressure
  • Skin rash
  • Swelling and redness in mucous membrane
  • Shock
  • Multi-organ failure

Diagnosis is made based on physical examination, blood or urine test or swaps from the cervix, vagina and throat.

Stages of Toxic Shock Syndrome

  1. High fever, sore throat, fatigue, muscle ache, nausea, fatigue, diarrhea, headache, dizziness (low blood pressure), confusion
  2. Reddish tongue, inflamed mucous membrane (eyes)
  3. Swelling of joints and eyelids
  4. Skin rash – generalized, flat and red (characterized by turning white when pressed)
  5. Shock occurs when the blood pressure cannot be maintained
  6. Skin rash disappears on recovery.
  7. Skin on palms of hands and soles of feet flake and peel off.
  8. Fingernails, toenails and hair may fall out.

Types of Toxic Shock Syndrome

  • Toxic Shock Syndrome due to bacteria Staphylococcus aureus
  • Streptococcal Toxic Shock Syndrome due to bacteria Streptococcus pyogenes

Treatment of Toxic Shock Syndrome

TSS is considered a medical emergency that required hospitalisation. An intravenous antibiotic will be prescribed to fight the bacteria infection, or medication to stabilize blood pressure and to prevent dehydration. Injections may also be given to suppress inflammation and increase body’s immunity. Also the cause of the bacterial infection will be removed, for instance, removal of the tampon or draining pus from the skin wound.

Complications of Toxic Shock Syndrome

If the internal organs are affected, it can lead to liver, kidney, heart failure, seizure and shock. Early detection of toxic shock syndrome has a much higher chance of recovery. The mortality rate is about 5-15% and rate of recurrence at 30-40%.

Toxic Shock Syndrome and Eczema

It is observed that patients recovering from TSS tend to develop chronic eczema. I couldn’t find literature on the likelihood of having TSS if one has eczema. I wonder if there’s increased risk since the skin of eczema patients tend to have staph bacteria colonization.

Prevention of Toxic Shock Syndrome

Certain precautions for menstruating female who uses tampon are to change the tampon every 4 to 8 hours and to use a low-absorbency tampon. Wash hands and keep skin cuts and wounds clean with frequent dressing change. TSS may recur, thus tampon should not be worn by those who had TSS before.

Anyone have experience with toxic shock syndrome? Do share, it will be useful to the rest of us and to be more aware of the risks.

For other life-threatening skin rash, see below:

Stevens Johnson Syndrome

Pemphigus Vulgaris

Staphylococcal Scalded Skin Syndrome

Life Threatening Skin Rash series – Stevens Johnson Syndrome

Stevens Johnson Syndrome by EczemaBlues.com

Pictures taken from http://dermnetnz.org/reactions/sjs-ten.html

Stevens-Johnson Syndrome (SJS) is a rare, severe disorder that causes pain, red/purplish skin, blisters and shedding of skin. It can be drug-induced or due to infection. It is a medical emergency and takes from weeks to months to recover. It is more common in adults or older people and men who use more of the possible drugs that trigger the SJS.

What Causes Stevens-Johnson Syndrome?

Its cause is largely drug-induced (more than 70%) or due to infection. However, genetics, family history and weakened immune system are also risk factors.

From Mayo’s Clinic website:

  • Anti-gout medications, such as allopurinol
  • Pain relievers such as acetaminophen (Tylenol, others), ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve)
  • Medications to fight infection, such as penicillin
  • Medications to treat seizures or mental illness (anticonvulsants and antipsychotics)
  • Radiation therapy

The infectious causes listed by Medscape are:

Viral diseases:

  • Herpes simplex virus
  • AIDS
  • Coxsackie viral infections
  • Influenza
  • Hepatitis
  • Mumps

In children, Epstein-Barr virus, enteroviruses and upper respiratory tract infection.

Bacterial diseases:

  • Group A beta-hemolytic streptococci
  • Diphtheria
  • Brucellosis
  • Lymphogranuloma venereum
  • Mycobacteria
  • Mycoplasma pneumoniae
  • Rickettsial infections
  • Tularemia
  • Typhoid

 Symptoms of Stevens-Johnson Syndrome

  • Flu-like symptoms
  • Rash – Pain, Red, Purplish Skin
  • Blisters
  • Shedding Skin (Nikolsky’s sign)
  • Eye-related – Painful red eye, purulent conjunctivitis, photophobia, blepharitis

Diagnosis is usually made via physical examination or skin biopsy.

Stages of Stevens-Johnson Syndrome

  1. Fever, sore throat or mouth sores
  2. Fatigue, cough, headache
  3. Swelling (face, tongue), Hives
  4. Rash – Pain, Red, Purplish Skin, Symmetric on face and torso
  5. Formation of blisters on skin and mucous membranes of mouth, nose, eyes, genitals
  6. Shedding of skin

Types of Stevens-Johnson Syndrome

The types are categorized by the extent of the body surface area (BSA) affected:

  • Stevens-Johnson syndrome: Less than 10% BSA detached
  • Toxic epidermal necrolysis: More than 30% of the BSA detached

Treatment of Stevens-Johnson Syndrome

Finding out the cause, in particular for drug-induced cases, is critical. Discontinue the drug. Treatment is to reduce pain, control itch, prevent dehydration, infection and inflammation. Oral corticosteroids and antibiotics may be prescribed. The patient is usually hospitalized.

Similar to Pemphigus Vulgaris, mouth/blister care is required.

Care of the Skin

Care of the skin includes application of lotions and wet dressings (wound care, wet compress). Particular to Stevens-Johnson Syndrome, eye care is also important to clean and prevent dry eyes.

Complications of Stevens-Johnson Syndrome

Complications include sepsis (blood infection), secondary skin infection (cellulitis), eye inflammation (tearing and scaring of cornea and even blindness) and permanent skin discoloration and damage (including nails).

Anyone have had SJS? Do share in the comments, thanks loads for spreading encouragement and experience.

Life Threatening Skin Rash series – Pemphigus Vulgaris

Pemphigus vulgaris eczema

Pemphigus Vulgaris (PV) is a rare, auto-immune disease that mistakes skin cells and mucous membranes as foreign matters and attacks them. This results in blisters and sores of the skin and the mucous membranes. It is more common in middle-aged and older people. PV is not infectious.

What Causes Pemphigus Vulgaris?

Pemphigus vulgaris is caused by an increase in the desmoglein antibodies where these antibodies incorrectly binds to protein desmoglein 3, which is found in desmosomes in the keratinocytes near the bottom of the epidermis. It then results in a separation of the skin layer and formation of blisters. The triggers of this faulty immune systems are not fully known though genetics play a part. 

Types of Pemphigus Vulgaris

Mucosal PV: Only the mucous membranes are affected, but not the skin. This may include the mucous membranes lining the mouth, nose, throat and genitals.

Mucocutaneous PV: Both the mucous membranes and skin are affected.

Symptoms of Pemphigus Vulgaris

  • Fever, Chills
  • Muscle aches
  • Rash, first appearing in mouth and then to rest of the skin
  • Blisters
  • Raw, moist, tender skin
  • Peeling Skin 
  • Fluid loss
  • Pain

Diagnosis is usually made by a skin specialist because it is uncommon, thus not often seen by general practitioners. Physical examination and lesion biopsy (including immunofluorescence to assess level of antibodies) are used to diagnose PV. Early treatment helps to prevent PV from being widespread.

Stages of Pemphigus Vulgaris

  1. Formation of blisters and sores around the mouth
  2. Bursting of mouth blisters, similar to ulcers
  3. More widespread blisters at other parts of skin with oozing, crusting and peeling of skin.
  4. Separation of outer layer skin with gentle touch (“Nikolsky’s sign”)
  5. Recovery of raw skin (6 to 8 weeks)

Treatment of Pemphigus Vulgaris

There is no treatment that specifically cures PV but instead treatment is to reduce blistering and limit flare-up. This is often via immunosuppressant therapy. Oral corticosteroids and immunosuppressive drugs may be prescribed. In more severe cases, it can be via intravenous methylprednisolone and cyclophosphamide (Pulsed therapy) which can last from 6 months to a year. Dosages are typically higher at the start of treatment and gradually reduces when the condition is stable (without flare-up). 

For severe cases, the patient will be hospitalized in the burn unit as the skin requires similar care to burns. Apart from immunosuppressant therapy, treatment also encompasses (i) pain relief, (ii) anesthetic lozenges to reduce mouth ulcer pain, (IiI) prevention of dehydration through intravenous drip, (Iv) medication to prevent bacterial or fungal infection

Care of the Skin

Care of the skin includes application of lotions and wet dressings (wound care, wet compress). Also minimize contact sports to avoid skin trauma.

Mouth Blisters and Care

If blisters occur in the voice box (larynx), the voice will be hoarse. If the blisters occur in the gullet, swallowing is painful. Where mouth blisters make it difficult to eat, supplements may be prescribed. Steroid, antiseptic or anesthetic mouth wash may also be prescribed for the mouth blisters. Avoid foods that may irritate the inside of mouth such as spicy, acidic or hard foods.

Pemphigus Vulgaris and Eczema

PV is sometimes diagnosed late as mistaken for dyshidrotic eczema or pompholyx which also has blisters. However, dyshidrotic eczema is not life threatening and believed to be due to stress or allergies.

Complications of Pemphigus Vulgaris

It is a difficult condition to treat as it is an autoimmune disease that has no cure. The mortality rate is 10%. There can also be complications associated with long-term use of oral corticosteroids and immunosuppressants. Other complications are secondary skin infection, dehydration and sepsis (bloodstream infection).

Anyone have had PV? Do share in the comments, thanks loads for spreading encouragement and experience!

Life Threatening Skin Rash series – Staphylococcal Scalded Skin Syndrome

Staphylococcal Scalded Skin Syndrome

Staphylococcal scalded skin syndrome (SSSS) is one skin rash that affects children (newborn to 5 years old), caused by infection from certain strains of Staphylococcus aureus bacteria. The bacteria produces toxins (epidermolytic toxins A and B) that bind to a molecule within the part of skin cell (demosomes) that adhere skin cells together. The damaged desmosome cannot continue to adhere skin cells and the skin break up, leading to fluid filling in the spaces (blisters) and peeling skin.  

What Causes Staphylococcal Scalded Skin Syndrome?

Staphylococcal scalded skin syndrome is caused by certain toxic strains (exotoxin of group II, phage type 71) of the staphylococcus bacteria found on skin. However, when there is broken skin from scratching, cut, a minor infection that can escalate to SSSS in children and in people with weakened immune system or renal insufficiency.

Symptoms of Staphylococcal Scalded Skin Syndrome

  • Fever
  • Chills
  • Lethargy
  • Skin redness (Erythema) 
  • Blisters
  • Raw, moist, tender skin
  • Peeling Skin 
  • Fluid loss
  • Physical examination is often sufficient to diagnose SSSS. Where unsure, other tests like skin biopsy, blood tests may be ordered.

Stages of Staphylococcal Scalded Skin Syndrome

Begins with signs of infection like fever, chills and irritability

Followed by skin redness and formation of lesions – for infants, lesions often start at diaper area or at umbilical cord (triggered by other conditions such as purulent conjunctivitis, nasopharyngeal infection or an infected umbilicus). For older children, usually the flexural areas and skin folds like the face, mouth/nose, neck, groin and armpit (triggered by impetigo or infected eczema or wound infection).

Skin wrinkles and Formation of blisters – Irregular, large and loose blisters 

Rupturing of blisters 

Formation of yellow crust, followed by drying and cracking

Peeling of outer layer skin (Exfoliation) – Revealing red, raw and wet skin. The outer skin falls off with gentle pressure, known as the Nikolsky’s sign.

Recovery of raw skin (takes from 5 to 10 days)

Treatment of Staphylococcal Scalded Skin Syndrome

Hospitalization is often required, at the burn unit of the hospital as the risk of complication is similar to burns. Treatment options include

  1. antibiotics to treat the staph bacteria infection,
  2. drip to prevent dehydration and
  3. care of the skin.

With SSSS, the child will feel pain at the skin and experience fluid and heat loss via exposed skin. Therefore, treatment will include caring for the child in a warm environment with minimal clothing. Pain control such as analgesia and paracetamol may be given to the child. The child should drink extra fluids to replenish the excess moisture loss from skin and prevent dehydration (check weight and urine for signs of dehydration).

Care of the Skin

Given the fragile skin, care must be taken when handling the skin to reduce trauma, such as when administering intravenous drips, creams and using non-adherent dressing to prevent further tearing of the skin. Moisturizer is applied to reduce fluid loss and soothe the skin until full recovering with smooth skin.

Staphylococcal Scalded Skin Syndrome and Eczema

Severe eczema presents higher risk due to broken skin (with scratching) and higher chance of staph bacteria colonization.

Complications of Staphylococcal Scalded Skin Syndrome

For children who are treated promptly, there is a high chance of recovery without scarring (mortality rate below 5%). In adults, it can be life threatening. 

Other possible complications are cellulitis (deeper skin infection), sepsis (bloodstream infection) and pneumonia, though not common.

Prevention of Staphylococcal Scalded Skin Syndrome

Prevention of outbreaks in neonatal and nursery day cares are critical – adults who carry the bacteria (5% of adults) can spread to infants who may develop SSSS due to weaker immunity. Isolating the infected healthcare worker, hand washing and alcohol hand rubs should be practiced in the ward. Towels should not be shared.

If you have experienced SSSS, do share in the comments, thanks!

Common Summer Skin Rashes in Kids Series: Insect Bites

Dr Robin Schaffran Dermatologist EczemaBlues

Dr Robin Schaffran, MD, Dermatologist

This is a 3-week series focused on Common Summer Skin Rashes in Kids, timely for those who are enjoying summer (Singapore is summer all year round, but many of you in US, UK and Canada are going through summer). While summer is a fun time for outdoor activities, there are certain rash that are more common during this time, and it’s my pleasure to have Dr. Robin Schaffran, M.D., a caring mom and Pediatric Dermatologist, to help us out.

More on Dr Robin: Dr. Robin is a board-certified Dermatologist and attending staff physician at Cedars Sinai Medical Center. She has also lectured extensively on the subject of skin cancer prevention and has been quoted in newspapers and magazines. She attended the University of Toronto Medical School where she graduated as a member of the Alpha-Omega-Alpha Honors Medical Society. She also has her own sunscreen, moisturizing and shampoo, body wash for children, available worldwide.

What is Insect Bite Rash

Rash is a common result from an insect bites, and during summer time, there are some insects that grow more, or come out during summer. There are various common insect bites, such as bed bug, mosquito bites, chigger bite.

MarcieMom: From your more than 10 years of practice, which insect bites (name two) are most common during summer, and most commonly affecting children?

Dr Robin: During the summer months, the 2 most common insect bites are mosquito bites and bee stings.

MarcieMom: How does the insect’s bite become a rash? Is it interaction with certain saliva or parts of the insect that trigger an inflammation?

Dr Robin: When an insect bites the skin it usually deposits a small amount of saliva into the skin. The rash or bump that results from the bite is due to an immune reaction in the skin directed against the foreign proteins in the saliva.

Appearance of Insect Bite Rash

MarcieMom: How is an insect bite diagnosed? And is it possible to know which insect the bite is from? Will the appearance of bites differ on eczema skin?

Dr Robin: There is a distinct look to an insect bite that makes it easy for a dermatologist to distinguish from eczema. Most bites appear as discrete red bumps that have a small spot in the center from where the insect bit. It is usually impossible to tell from the bite what insect caused the bite (other than certain spiders which result in a very distinct skin eruption).

Prevention of Insect Bite

MarcieMom: Can insect bite be prevented? Using insect repellent? For my toddler with eczema, I don’t put insect repellent on her (are these hypoallergenic?), instead I would put on the insect repellent patch. Are they equally effective?

Dr Robin: Insect bites are best prevented by using insect repellent. This is challenging with eczema skin because the insect repellents can irritate the skin, especially sensitive skin. If it’s not too hot, you can wear long sleeves and pants and spray the clothing with the insect repellent. Avon makes a product called ‘skin so soft’ which acts as an insect repellent (albeit not a very effective one). The repellent patches are okay but not as effective as the sprays.

Treatment of Insect Bite Rash

MarcieMom: I understand that complications can occur from insect bites, such as anaphylaxis, shock, diarrhea, cramps, swelling, hives and confusion. What are the complications that are due to the skin rash from insect bite?

Dr Robin: Most insect bites do not result in any complications other than itchy bumps that can result in a secondary skin infection from  repeated scratching.

MarcieMom: How should an insect bite be treated, and when will seeing a doctor be warranted?

Dr Robin: Insect bites are best treated with topical cortisone creams to treat the inflammation that leads to the itching. If the itching is severe or if the bite is suspected of being infected then it is best to see a doctor for evaluation and further treatment.

MarcieMom: Thank you Dr Robin, it is a very timely and protective series to know what to look out for during summer time while having fun with our children.

For previous posts in this series, see

Sunburn

Heat Rash

Common Summer Skin Rashes in Kids Series: Heat Rash

Dr Robin Schaffran Dermatologist EczemaBlues

Dr Robin Schaffran, MD, Dermatologist

This is a 3-week series focused on Common Summer Skin Rashes in Kids, timely for those who are enjoying summer (Singapore is summer all year round, but many of you in US, UK and Canada are going through summer). While summer is a fun time for outdoor activities, there are certain rash that are more common during this time, and it’s my pleasure to have Dr. Robin Schaffran, M.D., a caring mom and Pediatric Dermatologist, to help us out.

More on Dr Robin: Dr. Robin is a board-certified Dermatologist and attending staff physician at Cedars Sinai Medical Center. She has also lectured extensively on the subject of skin cancer prevention and has been quoted in newspapers and magazines. She attended the University of Toronto Medical School where she graduated as a member of the Alpha-Omega-Alpha Honors Medical Society. She also has her own sunscreen, moisturizing and shampoo, body wash for children, available worldwide.

What is Heat Rash

Heat rash is a common term, and in Asia, it may be thought of rashes that come out from consuming ‘heaty’ foods. Is that right? Let’s find out, with the help of Dr Robin.

Heat rash’s scientific term is Miliaria, also known as sweat rash or prickly rash. It is common during summer, especially if it’s hot and humid. It affects children especially due to their underdeveloped sweat glands, which are more prone to becoming blocked and therefore causing rash.

MarcieMom: Can you explain to us the interaction of heat and sweat, and the glands that cause a rash in miliaria?

Dr Robin: Miiaria occurs under conditions of high heat and humidity that lead to excessive sweating. Occlusion of the skin from too much clothing or blankets can aggravate the pooling of sweat on the skin surface leading to overhydration of the skin. In susceptible persons such as infants who have immature sweat glands, this often leads to transient blockage of the sweat ducts. Therefore, as more sweat is produced, there becomes and inability to secrete the sweat because of the blockage. This results in the appearance of a rash called miliaria.

MarcieMom: For a child with eczema whose eczema is triggered by sweat, what is the difference between atopic (to sweat?) versus a heat rash?

Dr Robin: Eczema is an inflammation of the skin, usually genetic, which is often aggravated by sweat and looks completely different than the appearance of miliaria. Eczema triggered by sweat looks like eczema triggered by any other trigger. Miliaria (heat rash) on the other hand, looks like small, tiny red bumps or vesicles which is usually asymptomatic.

Appearance of Heat Rash

Heat rash looks like dots or tiny pimples, and usually doesn’t require medical attention.

MarcieMom: Dr Robin, can you share with us where are the common body parts where heat rash occur? Is it more likely to be inside clothing due to heat trapped from wearing too much?

Dr Robin: The most common area of involvement for heat rash is the trunk area because of occlusion from clothing and blankets.

Treatment of Heat Rash

MarcieMom: When will heat rash require seeing a doctor?

Dr Robin: Heat rash is usually self limiting and asymptomatic so there is no reason to treat it. The reason to see a doctor is to ensure that the eruption is indeed heat rash and not something else that would require treatment.

MarcieMom: How should heat rash be treated at home? I’ve read that calamine lotion can be applied to sooth the irritability but will that be drying for the skin (thus not suitable for a child with eczema)?

Dr Robin: The mainstay of managing heat rash involves controlling heat and humidity so that sweating is not stimulated. Measures include removing occlusive clothing, limiting activity or providing air conditioning. Topical treatments involve lotions containing calamine and menthol and are for soothing purposes only and are not necessary. They can be drying to the skin and would not recommended to a patient with eczema.

MarcieMom: Drinking water is important in hot weather to prevent dehydration. Does drinking more water help prevent heat rash?

Dr Robin: Drinking water is important for hydration but heat rash is not a result of dehydration so drinking more water would have no effect on preventing heat rash.

MarcieMom: Thank you Dr Robin, your reply helps parents understand more about heat rash, and next week, we will be covering insect bites.

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