Thursday, 5 June 2014

Situations to remember (3)

WhatsApp diagnosis and missed biopsy

The female child has been diagnosed with bacterial skin infection affecting the scalp and the neck that responded well to antibiotics prescribed by another dermatologist. When the problem recurred she came to see me and I have seen the last prescription that was full of medications including steroids. While waiting for the culture and sensitivity result she received a short course (3 days) of broad spectrum antibiotic (amoxicillin with clavulanic acid). I was then on holiday, thus I was sent the result and follow up photos on WhatsApp. The result proved negative and the rash was extending. On WhatsApp my diagnosis has been generalized pustular psoriasis (GPP) or acute generalized exanthematous pustulosis (AGEP) and I have recommended immediate management including skin biopsy and patch testing. When I mentioned so I was told that “they” have made the same diagnosis. It was revealed later that other dermatologists have seen the extending rash while I was on holiday and prescribed methotrexate at the same time when the oral antibiotic course has just finished. The rash quickly disappeared. I saw her earlier today at my clinic and explained this “situation to remember”.  Rook’s states that it is probable that some cases previously reported as drug-induced GPP may in fact have been AGEP. AGEP is an acute, spontaneously healing reaction to drugs, usually antibiotics.  It looks similar to GPP. The presence of eosinophils in the inflammatory infiltrate is a helpful pointer to a drug cause and the spongiform pustulation at the margins is never as prominent as the spongiform pustules seen in pustular psoriasis. Interestingly, AGEP is more common in patients who have a history or family history of psoriasis. GPP itself might be provoked by drugs including withdrawal of systemic steroid therapy. Patients may have phases of ordinary psoriasis before or after the GPP.

This page was last updated in June 2014

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Main Works of Reference List (The first eight are my top favourites)

  • British National Formulary
  • British National Formulary for Children
  • Guidelines (BAD - BASHH - BHIVA - Uroweb)
  • Oxford Handbook of Genitourinary Medicine, HIV, and Sexual Health
  • Oxford Handbook of Medical Dermatology
  • Rook's Textbook of Dermatology
  • Simple Skin Surgery
  • Weedon's Skin Pathology
  • A Concise Atlas of Dermatopathology (P Mckee)
  • Andrews' Diseases of the Skin
  • Andrology (Nieschlag E FRCP, Behre M and Nieschlag S)
  • Bailey and Love's Short Practice of Surgery
  • Davidson's Essentials of Medicine
  • Davidson's Principles and Practice of Medicine
  • Fitzpatrick's Colour Atlas and Synopsis of Clinical Dermatology (Klaus Wolff FRCP and Richard Allen Johnson)
  • Fitzpatrick’s Dermatology in General Medicine
  • Ganong's Review of Medical Physiology
  • Gray's Anatomy
  • Hamilton Bailey's Demonstrations of Physical Signs in Clinical Surgery
  • Hutchison's Clinical Methods
  • Lever's Histopathology of the Skin
  • Lever's Histopathology of the Skin (Atlas and Synopsis)
  • Macleod's Clinical Examination
  • Martindale: The Complete Drug Reference
  • Oxford Handbook of Clinical Examination and Practical Skills
  • Oxford Textbook of Medicine
  • Practical Dermatopathology (R Rapini)
  • Sexually Transmitted Diseases (Holmes K et al)
  • Statistics in Clinical Practice (D Coggon FRCP)
  • Stockley's Drug Interactions
  • Treatment of Skin Disease: Comprehensive Therapeutic Strategies
  • Yen & Jaffe's Reproductive Endocrinology