| 🔥 Stevens-Johnson Syndrome / Toxic Epidermal Necrolysis |
- Prodrome: fever, malaise, sore throat, eye pain or flu-like illness.
- Painful red, dusky or purpuric macules.
- Blistering and epidermal detachment.
- Mucosal erosions affecting mouth, eyes, genitals or airway.
- Often occurs 1–3 weeks after a new medicine.
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- Clinical diagnosis and urgent drug history.
- Skin biopsy can support diagnosis.
- FBC, U&E, LFT, CRP, glucose, bicarbonate, clotting.
- Assess body surface area detached.
- SCORTEN may help risk-stratify in specialist care.
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- Stop suspected causative drug immediately.
- Urgent dermatology and ophthalmology review.
- Admit to hospital; severe cases need burns unit/ICU-level supportive care.
- Fluid, electrolyte, temperature and wound care.
- Analgesia, infection surveillance and eye protection.
- Systemic steroids, ciclosporin or IVIG are specialist decisions.
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| 🦠 Necrotising Fasciitis |
- Rapidly progressive erythema, swelling and severe pain.
- Pain often out of proportion to visible skin findings.
- Fever, tachycardia, hypotension or sepsis.
- Bullae, skin necrosis, crepitus or anaesthesia are late signs.
- Risk factors: diabetes, immunosuppression, trauma, surgery, varicella, injection drug use.
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- Clinical diagnosis - do not delay surgery for imaging.
- FBC, U&E, CRP, CK, lactate, blood cultures, clotting.
- CT/MRI may show gas/fascial oedema if stable, but normal imaging does not exclude.
- Definitive diagnosis often at surgical exploration.
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- Immediate surgical referral for exploration/debridement.
- Sepsis 6 / IV fluids / oxygen as needed.
- Broad-spectrum IV antibiotics plus toxin-suppressing therapy according to local policy.
- ICU involvement if shock or organ dysfunction.
- Repeated debridement may be needed.
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| 👶 Staphylococcal Scalded Skin Syndrome |
- Usually infants and young children.
- Fever, irritability and diffuse tender erythema.
- Flaccid bullae and superficial peeling.
- Positive Nikolsky sign.
- Mucous membranes usually spared, helping distinguish from SJS/TEN.
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- Clinical diagnosis.
- Swabs/cultures from possible primary site: nose, throat, conjunctiva, umbilicus or skin infection.
- Blood cultures if systemically unwell.
- Skin biopsy if diagnosis uncertain: split in superficial epidermis.
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- Admit, especially children or extensive disease.
- IV anti-staphylococcal antibiotics according to local policy.
- Fluid, temperature and pain management.
- Gentle skin care and non-adherent dressings.
- Monitor for dehydration and secondary infection.
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| 🫁 Angioedema / Anaphylaxis |
- Sudden swelling of lips, tongue, face, eyelids or throat.
- May have urticaria, flushing or itch if histamine-mediated.
- Airway symptoms: voice change, stridor, throat tightness, drooling.
- Anaphylaxis: airway/breathing/circulation compromise with rapid onset.
- ACE inhibitor angioedema may occur without urticaria.
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- Clinical diagnosis - assess airway immediately.
- Oxygen saturations, BP, pulse, respiratory rate.
- Serum tryptase if anaphylaxis suspected, but do not delay treatment.
- C4 and C1 esterase inhibitor tests later if hereditary angioedema suspected.
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- Airway first - call anaesthetics/ICU early if tongue or throat swelling.
- If anaphylaxis: IM adrenaline immediately, high-flow oxygen, IV fluids, repeat adrenaline if needed.
- Antihistamines and steroids are adjuncts, not first-line for anaphylaxis.
- Stop ACE inhibitor permanently if ACE inhibitor angioedema suspected.
- Hereditary angioedema: specialist treatment such as C1 inhibitor concentrate or icatibant depending on local policy.
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| 🩸 Purpura Fulminans / DIC |
- Sudden widespread purpura, petechiae or ecchymoses.
- Skin necrosis, retiform purpura or gangrene.
- Usually associated with severe sepsis, meningococcaemia, pneumococcal sepsis, trauma, malignancy or obstetric catastrophe.
- Shock, bleeding, thrombosis and organ failure may occur.
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- FBC: thrombocytopenia.
- Clotting: prolonged PT/APTT, low fibrinogen, raised D-dimer.
- Blood cultures and septic screen.
- Lactate, U&E, LFT, ABG/VBG.
- Skin biopsy may show small-vessel thrombosis if needed later.
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- Medical emergency - treat sepsis immediately.
- Broad-spectrum IV antibiotics if infection suspected.
- IV fluids, vasopressors and ICU support if shock.
- Blood products guided by bleeding, fibrinogen, platelets and haematology advice.
- Treat underlying cause.
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| 🌡 Erythroderma |
- Generalised erythema and scaling affecting >90% body surface area.
- Pruritus, pain, fever, malaise or lymphadenopathy.
- Can cause fluid loss, hypothermia, high-output cardiac failure and sepsis.
- Causes: eczema, psoriasis, drug reaction, cutaneous T-cell lymphoma.
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- FBC, U&E, LFT, CRP, albumin, cultures if infection suspected.
- Skin biopsy to identify cause.
- Drug history and review of dermatology history.
- Consider lymph node assessment if lymphoma suspected.
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- Admit if systemically unwell, frail, extensive, dehydrated or temperature unstable.
- Stop suspected causative drugs.
- Emollients, wet wraps/dressings and topical steroids under specialist guidance.
- Fluid, electrolyte, temperature and nutrition support.
- Urgent dermatology review.
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| 💊 Acute Generalised Exanthematous Pustulosis |
- Sudden eruption of many small non-follicular sterile pustules.
- Background erythema, often flexural/intertriginous.
- Fever, malaise and neutrophilia.
- Usually triggered by drugs, especially antibiotics or calcium-channel blockers.
- Often starts within days of exposure.
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- Clinical diagnosis and drug timeline.
- FBC often shows neutrophilia.
- U&E/LFT if severe or systemic symptoms.
- Skin biopsy if diagnosis uncertain.
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- Stop offending drug.
- Supportive care: fluids, antipyretics, emollients.
- Topical steroids for symptoms.
- Admit if extensive, systemically unwell or diagnostic uncertainty.
- Usually resolves within 1–2 weeks after drug withdrawal.
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| 🧠 HSV Encephalitis with Skin/Mucosal Clues |
- Fever, headache, confusion, seizures or focal neurology.
- May have oral/genital vesicles, but skin lesions may be absent.
- Rapid deterioration if untreated.
- Temporal lobe features: behaviour change, dysphasia, memory disturbance.
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- Urgent CT/MRI brain if indicated before LP.
- CSF: lymphocytes, raised protein, normal glucose; HSV PCR.
- MRI may show temporal lobe involvement.
- Blood tests and sepsis screen.
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- Start IV aciclovir immediately if suspected - do not wait for PCR.
- Admit urgently under acute medicine/neurology/ID.
- Seizure management and neurocritical care if needed.
- Adjust aciclovir dose for renal function and maintain hydration.
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| 👁 Periorbital / Orbital Cellulitis |
- Red, swollen eyelids with fever or pain.
- Orbital red flags: proptosis, painful/restricted eye movements, diplopia, reduced vision, RAPD.
- Often follows sinusitis, trauma or skin infection.
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- Assess visual acuity, pupils, eye movements and colour vision.
- FBC, CRP, blood cultures if febrile.
- CT orbits/sinuses if orbital cellulitis suspected.
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- Suspected orbital cellulitis needs same-day hospital admission.
- IV antibiotics according to local policy.
- Urgent ophthalmology and ENT review.
- Surgical drainage if abscess or poor response.
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| 🔥 Severe Cellulitis / Erysipelas |
- Rapidly spreading erythema, warmth, swelling and pain.
- Fever or systemic upset.
- Lymphangitis or regional lymphadenopathy.
- Face, periorbital area, hand, genital area or immunosuppression increases concern.
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- Clinical diagnosis.
- FBC, CRP, U&E if systemically unwell.
- Blood cultures if sepsis or severe infection.
- Consider imaging if abscess, foreign body, osteomyelitis or necrotising infection suspected.
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- Oral antibiotics for mild cases according to local guidance.
- Urgent hospital assessment if sepsis, rapidly spreading infection, severe pain, immunosuppression, facial/orbital involvement or treatment failure.
- IV antibiotics if severe or unable to tolerate oral treatment.
- Mark erythema edge and review response.
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| 🟣 Meningococcal Septicaemia Rash |
- Non-blanching petechial or purpuric rash.
- Fever, limb pain, cold hands/feet, toxic appearance.
- Neck stiffness, photophobia or altered consciousness may occur.
- Can progress rapidly to shock and DIC.
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- Clinical emergency - do not delay treatment for tests.
- Blood cultures, FBC, CRP, U&E, clotting, lactate when possible.
- LP only when safe and after senior assessment.
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- Immediate emergency transfer/admission.
- Give parenteral antibiotics urgently if meningococcal disease suspected, following local/NICE pathway.
- Sepsis resuscitation and ICU support if shock.
- Public health notification and contact prophylaxis.
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