Book Review

Dermatology in Emergency Care

N Engl J Med 1998; 338:478February 12, 1998

Article

Dermatology in Emergency Care
By Libby Edwards. 407 pp., illustrated. New York, Churchill Livingstone, 1997. $105. ISBN: 0-443-07952-8

The practice of dermatology is not normally associated with the emergency room. Nevertheless, persons with acute dermatologic problems regularly crop up in the casualty department, and an informal survey of my own accident and emergency department at St. Thomas's Hospital indicates that about 20 percent of all cases involve a skin problem. I recollect, during my years as a dermatology registrar at the Royal Victoria Infirmary, Newcastle upon Tyne, being frequently called in to see members of a large family with hereditary angioedema, always on a Friday night. It turned out that they regularly got involved in punch-ups at the local pubs, evidently under the influence of the famous and potent Newcastle brown ale. I got very good at administering intravenous fresh-frozen plasma to inebriated Geordies during that period.

Many dermatologic emergencies are dealt with by the dermatology resident on call. However, others are dealt with by accident and emergency personnel who may have acquired few dermatologic skills and who in any case are tempted to temporize by referring the patient to the regular dermatology clinic. The sudden onset of a widespread itchy rash in an infant is considered an emergency by a parent but may be perceived as less serious by those habitually dealing with victims of traffic accidents, cardiac arrests, cerebrovascular accidents, and coma.

As a vade mecum for accident and emergency staff and a compendium of practical advice with enough scientific background to give the book authority, Dermatology in Emergency Care is to be welcomed. The subject is addressed in terms of morphologic classification, as befits a book that is destined to be used as a working handbook. There is a section dealing with principles of diagnosis, diagnostic procedures, and principles of therapy. I am always surprised how often otherwise well informed colleagues deal perfunctorily with the dominant symptom of acute skin disease, itch. The clinical significance of itch as a symptom of skin and systemic disease deserves to be discussed. Edwards does devote space to its management, and I entirely share her frustration at the lack of effective antipruritic agents. Doxepin cream is of value in some patients with histamine-mediated itch (such as that due to insect-bite reactions, or atopic eczema), but it does cause drowsiness owing to its systemic absorption, and 1 percent menthol cream affords mild relief to almost all patients with itchy skin. Capsaicin cream is impractical — patients will not use it because of its irritant qualities.

I was unable to find any mention of the differential diagnosis of angioedema and its management. This must be an oversight, because it is one of the true dermatologic emergencies and seems to be increasingly common — often as a manifestation of insect-venom reactions and peanut and latex allergies and as a drug reaction, especially to angiotensin-converting–enzyme inhibitors. Oropharyngeal angioedema engenders panic in both patients and health care professionals, although it is hardly ever life-threatening. Except in the case of wasp-venom or bee-venom reactions, it is usually not associated with generalized anaphylaxis, as incorrectly asserted by the author. Intramuscular epinephrine, intravenous chlorpheniramine, and hydrocortisone (it does have a rapid cell-membrane action) are effective, and I often use a 2 percent phenylephrine (ephedrine) spray for a localized mucosal reaction. Patients with hereditary angioedema may have bowel edema, which presents as an abdominal emergency, and the existence of patients with numerous abdominal scars bears witness to the frequency with which this presentation of C1 esterase deficiency is misinterpreted.

It would also have been nice if Edwards had discussed acute erythroderma (exfoliative dermatitis), because it is not only a recognized dermatologic emergency with a significant mortality rate but also a paradigm for the management of severe dermatologic inflammation. Elderly patients, especially those living in inadequately heated homes, become paradoxically hypothermic as a result of excessive heat loss, and cardiovascular failure may also ensue from the low peripheral resistance that is a consequence of vasodilatation in patients with preexisting heart disease. They must be kept warm, with regular monitoring of fluid balance, electrolyte levels, blood pressure, and cardiac function.

Dr. Edwards justifiably discusses a large number of skin disorders that, although unlikely to be found in the emergency room, need to be included in the differential diagnosis of conditions that might. I enjoyed reading her chapter on cutaneous presentations of patients with AIDS — some well-known textbooks of dermatology include less well illustrated and referenced accounts. I did not know that very long eyelashes are a feature of some patients with AIDS, and I was relieved to learn that Dr. Edwards believes there is no specific therapy for this phenomenon. The book finishes with an appendix consisting of no less than 44 instructional handouts for patients. I am not convinced that these handouts, which are not indexed, add anything to the book. I have tried to write one or two myself, and I know how difficult it is to get them right. For example, the handout on chronic urticaria is correct as far as it goes, but patients need to be reassured that their recurrent hives do not represent an outward manifestation of cancer, AIDS, or other chronic infection and that special diets and allergy tests are rarely of any avail.

Finally, a future edition should include a chapter on recognized dermatologic pitfalls — for example, eczema herpeticum masquerading as a flare-up of atopic dermatitis, the rash of acute dermatomyositis masquerading as acute contact dermatitis, purpura due to meningococcemia masquerading as a viral exanthem or drug reaction, and the rash of acute contact dermatitis masquerading as almost anything.

The book fills an important niche. It contains a lot of very good material, and the author should accept the challenge of producing an even better version in the near future.

Malcolm W. Greaves, M.D., Ph.D.
St. John's Institute of Dermatology, London SE1 7EH, United Kingdom

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