DERMATOLOGY
SYMPTOMS/EXAM
■ Stage 1:Intact skin, local tissue erythema
■ Stage 2:Penetrate the epidermis or dermis but not the subcutaneous
tissue
■ Stage 3:Extend through the dermis into the subcutaneous tissue
■ Stage 4:Extend beyond the subcutaneous tissue through to the deep fas-
cia and may involve muscle and bone
DIFFERENTIAL
Cellulitis
DIAGNOSIS
■ Clinical diagnosis is based mainly on physical exam.
■ Stage 4 ulcers are often underestimated due to fistula formation, eg, a
seemingly superficial skin defect may mask extensive deep tissue necrosis.
Eschar may also make it difficult to determine depth of wound.
TREATMENT
■ Prevention:Ideal positioning of bed-bound patients, position changes at
least every 2 hours, pressure reducing devices
■ Treatment: Fundamentals include proper nutrition, pain management,
reducing tissue pressure, maintaining a moist environment, wound
debridement, and fighting infection.
■ Stage 1: More intensive prevention measures
■ Stage 2: Occlusive or semipermeable dressing to maintain moist
wound environment; avoid wet to dry dressings
■ Stage 3: Remove necrotic tissue, manage infections, and maintain
moist wound environment.
■ Stage 4: Undermining and tunneling in consultation with wound spe-
cialist, eg, plastic surgeon
COMPLICATIONS
■ Common in stage 3 and 4 ulcers
■ Chronic pain, depression, social isolation
■ Cellulitis and osteomyelitis especially with MRSA, VRE, and multiple-
resistant Gram-negative bacilli leading to bacteremia, sepsis, and death
■ Rare: Fistulas, heterotrophic calcification, systemic amyloidosis, squamous
cell carcinoma
DRUG ERUPTIONSETIOLOGY
■ Appear within 1 to 2 weeks after an offending drug is taken, except or
PCN, which can take longer
■ Most drug eruptions are type IV delayed, cell-mediated reactions, but drug
eruptions resulting from type I, II, and III reactions also occur.
SYMPTOMS/EXAM
■ Exanthematous: Resemble erythematous, morbilliform, skin eruptions
from viral or bacterial infections, widespread symmetric maculopapular
eruptions