Dermatology nurse specialist Julie Van Onselen explains how to recognise and manage acute dermatology conditions requiring urgent or emergency referral when they present in primary care. Complete the full module on Nursing in Practice 365 today.
Skin conditions are the commonest presentations in general practice, making up 24% of consultations. Dermatology emergencies can sometimes present in primary care, and nurses need to know when an urgent referral is needed. Loss of normal skin function can rapidly result in skin failure and in some cases this can be life threatening.
This module will discuss key skin conditions that require urgent or emergency treatment, explaining how to recognise and manage them in primary care. The treatment advice is based on current NICE, British Association of Dermatology (BAD) and Primary Care Dermatology Society (PCDS) guidance.
Learning objectives:
• Improve understanding of acute skin conditions and when to refer to Dermatology specialist services.
• Recognise clinical history and features associated with key dermatology emergencies.
• Enhance knowledge of management and treatment options.
• Understand more about the appropriate supportive care of acute skin conditions.
• Be aware of the key red flags in acute dermatology presentations.
1. Erythroderma
Erythroderma is characterised by widespread erythema and oedema or papulation of the skin affecting over 90% of the skin surface.
It can develop rapidly, with very acute skin redness and shedding. (See image 1.)
While erythroderma is quite rare, GPNs need to be aware this is a dermatological emergency; they should immediately discuss this presentation with the duty GP. The patient will require immediate referral to A&E for urgent supportive care.
The patient is likely to be experiencing severe skin pain; analgesia can be administered in primary care to help manage pain while the patient is transferring to A&E.
Complications of erythroderma include: infection and septicaemia, due to loss of skin barrier function; hypothermia and dehydration; tachycardia and high-output cardiac failure, due to loss of thermoregulation and dehydration; and peripheral oedema, due to rapid skin exfoliation with loss of albumin and protein.
Causes of erythroderma include severe eczema and psoriasis, drug reactions, skin malignancy (cutaneous T-cell lymphoma, Sezary syndrome) and infection (staphylococcus scaled skin syndrome), while around 20% of cases are idiopathic.1
2. Eczema herpeticum
An 8-year-old boy with atopic eczema develops clustered painful vesicles on his face (cheeks, radiating towards his eyes) and hands. The eruption developed rapidly over 2 days. He is unwell with a temperature of 38oC. His mother has recently had a cold sore.
1. Why does eczema herpeticum develop in children with eczema?
Eczema herpeticum develops rapidly in people with atopic eczema, on the first episode of contact with herpes simplex infection, caused by herpes virus type 1 or 2.
A rapid change in eczema, with painful clustered vesicles, is suspicious for eczema herpeticum – especially in a feverish, unwell child. (See image 2).
It is usually seen in children, but can affect any age group. Eczema herpeticum is different to a usual flare of eczema, as it can affect areas of the skin that are usually unaffected by the patient’s eczema. The lesions are vesicles, which are painful, itchy and formed in clusters; they are monomorphic and appear punched out.2 Eczema herpeticum can spread, with new areas affected over 7-10 days. Secondary bacterial infection is often seen, and the patient is unwell, with fever and malaise.
Eczema herpeticum is diagnosed clinically based on acute signs and symptoms in primary care. Occasionally viral swabs – which can be taken in primary care – may be required to confirm the diagnosis; if clinically suspected it is best to start treatment, however, as a swab result will take a few days to come back, and treatment is required within 48 hours.
2. How should this child be managed?
Treatment is with systemic oral acyclovir. If severe then an urgent Dermatology consultation in secondary care is required, and the patient may be admitted for IV acyclovir. If eczema herpeticum is near the eyes, urgent ophthalmic assessment is required to assess for eye complications.2 Eczema herpeticum can be a single episode or recurrent. Patients with severe atopic eczema, who have developed the condition at an early age are more likely to have recurrent episodes.3
Julie Van Onselen is a Dermatology Lecturer Practitioner at Dermatology Education Partnership Ltd and clinical advisor for the National Eczema Society and Check4Cancer
To read and complete the full module visit Nursing in Practice 365.
References
- Katugampola R (2022) Emergency Dermatology. In Chowdhury MU, Griffiths TW and Finlay AY (eds) Dermatology Training -The Essentials. Chapter 16:211-212
- PCDS. Eczema herpeticum. 2024
- Seegräber M, Worm M, Werfel T et al. Recurrent eczema herpeticum – a retrospective European multicenter study evaluating the clinical characteristics of eczema herpeticum cases in atopic dermatitis patients. J Eur Acad Dermatol Venereol 2020;34(5):1074-1079
