Dermatological emergencies — Viva

Opening (30 s)

"Dermatological emergency — one-line definition and the first move that is always the same."

Q1: SJS/TEN versus SSSS (3 min)

How do you classify SJS, overlap, and TEN? How does SSSS differ at the bedside and on mechanism?^[23][5]

Model answer. Bastuji-Garin 1993: SJS is detachment below 10 percent BSA with widespread purpuric macules or flat atypical targets; overlap is 10 to 30 percent; TEN with spots is above 30 percent. SSSS is toxin-mediated cleavage of desmoglein-1 in the stratum granulosum; Leung: absence of mucosal involvement. Treat with intravenous anti-staphylococcal beta-lactam (nafcillin, oxacillin, or flucloxacillin); Gray: bland emollients and a less-is-more skin-care approach.^[23][5][4]

Q2: DRESS (2 min)

What did the prospective RegiSCAR study actually count?^[6]

Model answer. 201 potential cases, 117 probable or definite. Eosinophilia 95 percent, visceral involvement 91 percent, high fever 90 percent, atypical lymphocytes 67 percent, lymphadenopathy 54 percent. Culprits: antiepileptics 35 percent, allopurinol 18 percent, sulphonamides/dapsone 12 percent, other antibiotics 11 percent. Median latency 22 days (IQR 17 to 31). Two acute deaths; mortality lower than prior publications.^[6]

Q3: Necrotising fasciitis and LRINEC (3 min)

Can a low LRINEC send the patient for imaging instead of theatre?^[11][12]

Model answer. No. Delay to diagnosis and surgical management is associated with increased mortality. Fever sensitivity/specificity 46.0/77.0 percent; haemorrhagic bullae 25.2/95.8; hypotension 21.0/97.7 — absence of any one sign does not rule NSTI out. CT 88.5/93.3 percent versus plain radiography 48.9/94.0 percent. LRINEC of 6 or more: 68.2/84.8 percent; of 8 or more: 40.8/94.9 percent. Tarricone extremities: 49.39/83.17 percent. Do not use LRINEC to rule out.^[11][12]

Q4: Anaphylaxis versus HAE (2 min)

Give the epinephrine dose. How is hereditary angioedema treated differently from anaphylaxis?^[18][16][15]

Model answer. IM epinephrine 0.01 mg/kg (1:1000), maximum single dose 0.5 mg, repeat after 5 to 10 minutes; no absolute contraindications. HAE is autosomal dominant C1-INH disease (about 1 in 50 000); most cases are type I. Betschel frames contemporary care as targeted therapies for acute attacks and long-term prophylaxis, not generic anaphylaxis drugs.^[18][16][15]

Q5: SCORTEN (2 min)

List the seven components.^[9]

Model answer. Age above 40 years; malignancy; heart rate above 120 per minute; initial epidermal detachment above 10 percent; serum urea above 10 mmol/L; serum glucose above 14 mmol/L; bicarbonate below 20 mmol/L. Each point odds ratio 3.45. TEN mortality about 30 percent. Do not quote the textbook 3/12/35/58/90 percent bands unless you have the table in front of you — they are not in the abstract.^[9]

References10ShowHide

1. [4]Gray L, Hansen AM, Cipriano SD Pediatric Staphylococcal Scalded Skin Syndrome: A Systematic Review of the Literature to Inform Work-Up and Management Pediatr Dermatol, 2025.PMID 40650480
2. [5]Leung AKC, Barankin B, Leong KF Staphylococcal-scalded skin syndrome: evaluation, diagnosis, and management World J Pediatr, 2018.PMID 29508362
3. [6]Kardaun SH, Sidoroff A, Valeyrie-Allanore L, et al. Drug reaction with eosinophilia and systemic symptoms (DRESS): an original multisystem adverse drug reaction. Results from the prospective RegiSCAR study Br J Dermatol, 2013.PMID 23855313
4. [9]Bastuji-Garin S, Fouchard N, Bertocchi M, et al. SCORTEN: a severity-of-illness score for toxic epidermal necrolysis J Invest Dermatol, 2000.PMID 10951229
5. [11]Fernando SM, Tran A, Cheng W, et al. Necrotizing Soft Tissue Infection: Diagnostic Accuracy of Physical Examination, Imaging, and LRINEC Score: A Systematic Review and Meta-Analysis Ann Surg, 2019.PMID 29672405
6. [12]Tarricone A, Mata K, Gee A, et al. A Systematic Review and Meta-Analysis of the Effectiveness of LRINEC Score for Predicting Upper and Lower Extremity Necrotizing Fasciitis J Foot Ankle Surg, 2022.PMID 34657810
7. [15]Betschel SD, Banerji A, Busse PJ, et al. Hereditary Angioedema: A Review of the Current and Evolving Treatment Landscape J Allergy Clin Immunol Pract, 2023.PMID 37116793
8. [16]Sinnathamby ES, Issa PP, Roberts L, et al. Hereditary Angioedema: Diagnosis, Clinical Implications, and Pathophysiology Adv Ther, 2023.PMID 36609679
9. [18]Hearrell M, Anagnostou A Diagnosis and management of anaphylaxis J Food Allergy, 2020.PMID 39022137
10. [23]Bastuji-Garin S, Rzany B, Stern RS, et al. Clinical classification of cases of toxic epidermal necrolysis, Stevens-Johnson syndrome, and erythema multiforme Arch Dermatol, 1993.PMID 8420497