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Target exams

Red flags

• A patient with a rapidly evolving purpuric rash, fever and altered mental state may have meningococcal septicaemia — this is a medical emergency requiring intravenous antibiotics within the first hour, not a leisurely dermatological workup
• A patient with target lesions, blistering, skin pain and mucosal involvement at two or more sites has Stevens-Johnson syndrome or toxic epidermal necrolysis — measure the affected body surface area, stop all suspect drugs immediately, and transfer to a burns or intensive care unit
• A patient with new acanthosis nigricans that is rapidly progressive, involves the oral mucosa or the palms (tripe palms), or occurs in a non-obese patient without insulin resistance may have malignant acanthosis nigricans from an underlying intra-abdominal adenocarcinoma — search for GI malignancy urgently
• A patient with livedo reticularis or livedo racemosa, a history of thrombosis or recurrent pregnancy loss, and a prolonged APTT may have antiphospholipid syndrome — this is a prothrombotic disorder with a risk of arterial and venous thrombosis and catastrophic antiphospholipid syndrome
• A patient with palpable purpura, fever, arthralgia, abdominal pain and renal impairment has small-vessel vasculitis — check the urine for blood and protein and the blood for cryoglobulins, hepatitis C, ANCA and complement, because the skin is the visible sign of a systemic process