Approach To The Dermatologic Patient In The Emergency Department

William J. Brady

Marcus L. Martin

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The chief complaint "rash" is encountered in approximately 5 percent of ED visits nationwide; additionally, cutaneous findings are felt to contribute significantly toward the correct diagnosis and management in another 5 percent. In children, rashes are encountered even more often. A medical record survey of pediatric patients presenting to an academic ED revealed that 31 percent of cases primarily involved a dermatologic aspect; an additional 9 percent of ED patients demonstrated various skin findings that did not relate to the chief complaint, yet may have contributed to the final diagnosis and management plan. 1 The dermatologic syndromes seen in the ED span the spectrum of cutaneous disease. The majority of skin lesions involve infections, irritants, and allergies. 2 Fortunately, few presentations represent life- or limb-threatening skin disorders. Visual diagnosis using pattern recognition is the key to cutaneous diagnosis. The recommended approach to the patient with skin disease in the ED is (assuming resuscitation or stabilization is not required):

• Determine the chief complaint.

• Obtain a brief history (duration, rate of progression, location of lesions).

• Perform the dermatologic examination (morphology, distribution).

• Formulate the differential diagnosis based upon lesion morphology and distribution.

• Elicit additional issues from the history (associated complaints, comorbidity, medications, exposures) and include/exclude syndromes in the differential based upon this information.

• Perform ancillary investigations, if necessary.

• Obtain dermatologic consultation if necessary and/or arrange for appropriate referral (primary care or dermatologic). DIAGNOSTIC APPROACH

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