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Nikolskys Sign

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61. Percutaneous Transluminal Coronary Angioplasty (Overview)

) guidelines on the management of NSTE-ACS (updated in 2014 [ ] ) recommend an early invasive strategy in most cases, with timing as follows: Immediate (within 2 hours) - Patients with refractory angina, recurrent angina after initial treatment, signs/symptoms of heart failure, new/worsening mitral regurgitation, hemodynamic instability, sustained ventricular tachycardia, or ventricular fibrillation Early (within 24 hours) - None of the immediate characteristics but new ST-segment depression, a GRACE risk (...) Foundation/AHA guidelines for management of unstable angina/NSTEMI recommend the use of an early invasive strategy or ischemia-guided strategy in patients with NSTE-ACS. An ischemia-guided approach is recommended for patients with a low-risk score (TIMI 0 or 1, GRACE < 109). Other patients will benefit from an early invasive strategy stratified by timing as follows: Immediate (within 2 hours) - Patients with refractory or recurrent angina with initial treatment, signs/symptoms of heart failure, new

2014 eMedicine.com

62. Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis (Diagnosis)

and bullae. Lesions, with the exception of central bullae, are typically flat. (Lesions of erythema multiforme are more likely to be palpable.) Less frequently, the initial eruption may be scarlatiniform. See the image below. Extensive blistering and sloughing on the back. Nondenuded areas have a wrinkled paper appearance. A Nikolsky sign is easily demonstrated by applying lateral pressure to a bulla. With regard to the arrangement of lesions, individual macules are found surrounding large areas (...) . In the study, the time from the onset of skin signs to arrest of disease progression and to complete reepithelialization was significantly shorter in the cyclosporine group. All patients in the cyclosporine group survived versus 50% surviving in the cyclophosphamide group. An open-label phase II trial of adults and a retrospective chart review of patients with Stevens-Johnson syndrome/toxic epidermal necrolysis treated with cyclosporine have also demonstrated a decrease in death and the progression

2014 eMedicine.com

63. Drug Eruptions (Diagnosis)

after drug withdrawal and any reaction with readministration Physical examination should address clinical features that may indicate a severe, potentially life-threatening drug reaction, including the following: Mucous membrane erosions Blisters Nikolsky sign Confluent erythema Angioedema and tongue swelling Palpable purpura Skin necrosis Lymphadenopathy High fever, dyspnea, or hypotension It is important to appreciate the morphology and physical features of drug eruptions, as follows: Acneiform (...) and who suddenly develops a symmetric cutaneous eruption. Morbilliform eruption localized to striae has been described with clindamycin. [ ] Morbilliform drug eruption. Signs and symptoms The first steps in the history are as follows: Review the patient’s complete medication list, including prescription and over-the-counter drugs Document any history of previous adverse reactions to drugs or foods Consider alternative etiologies (eg, viral exanthems and bacterial infections) Note any concurrent

2014 eMedicine.com

64. Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis (Treatment)

and bullae. Lesions, with the exception of central bullae, are typically flat. (Lesions of erythema multiforme are more likely to be palpable.) Less frequently, the initial eruption may be scarlatiniform. See the image below. Extensive blistering and sloughing on the back. Nondenuded areas have a wrinkled paper appearance. A Nikolsky sign is easily demonstrated by applying lateral pressure to a bulla. With regard to the arrangement of lesions, individual macules are found surrounding large areas (...) . In the study, the time from the onset of skin signs to arrest of disease progression and to complete reepithelialization was significantly shorter in the cyclosporine group. All patients in the cyclosporine group survived versus 50% surviving in the cyclophosphamide group. An open-label phase II trial of adults and a retrospective chart review of patients with Stevens-Johnson syndrome/toxic epidermal necrolysis treated with cyclosporine have also demonstrated a decrease in death and the progression

2014 eMedicine.com

65. Percutaneous Transluminal Coronary Angioplasty (Treatment)

) guidelines on the management of NSTE-ACS (updated in 2014 [ ] ) recommend an early invasive strategy in most cases, with timing as follows: Immediate (within 2 hours) - Patients with refractory angina, recurrent angina after initial treatment, signs/symptoms of heart failure, new/worsening mitral regurgitation, hemodynamic instability, sustained ventricular tachycardia, or ventricular fibrillation Early (within 24 hours) - None of the immediate characteristics but new ST-segment depression, a GRACE risk (...) Foundation/AHA guidelines for management of unstable angina/NSTEMI recommend the use of an early invasive strategy or ischemia-guided strategy in patients with NSTE-ACS. An ischemia-guided approach is recommended for patients with a low-risk score (TIMI 0 or 1, GRACE < 109). Other patients will benefit from an early invasive strategy stratified by timing as follows: Immediate (within 2 hours) - Patients with refractory or recurrent angina with initial treatment, signs/symptoms of heart failure, new

2014 eMedicine.com

66. Pemphigus Foliaceus (Treatment)

with pemphigus that is relatively resistant to systemic steroid therapy. [ ] Toth and Jonkman also reported on successful therapy with intravenous immunoglobulin (low dose). [ ] References Nikolski PV. Materiali K.uchenigu o pemphigus foliaceus [doctoral thesis]. Kiev . 1896. Chorzelski T, Jablonska S, Blaszczyk M. Immunopathological investigations in the Senear-Usher syndrome (coexistence of pemphigus and lupus erythematosus). Br J Dermatol . 1968 Apr. 80(4):211-7. . Jablonska S, Chorzelski TP, Beutner EH (...) Research. N Engl J Med . 2000 Jul 6. 343(1):23-30. . Fariba G, Ayatollahi A, Hejazi S. Pemphigus foliaceus. Indian Pediatr . 2012 Mar 8. 49(3):240-1. . Metry DW, Hebert AA, Jordon RE. Nonendemic pemphigus foliaceus in children. J Am Acad Dermatol . 2002 Mar. 46(3):419-22. . Daoud YJ, Foster CS, Ahmed R. Eyelid skin involvement in pemphigus foliaceus. Ocul Immunol Inflamm . 2005 Sep-Oct. 13(5):389-94. . Uzun S, Durdu M. The specificity and sensitivity of Nikolskiy sign in the diagnosis of pemphigus. J

2014 eMedicine.com

67. Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis (Overview)

and bullae. Lesions, with the exception of central bullae, are typically flat. (Lesions of erythema multiforme are more likely to be palpable.) Less frequently, the initial eruption may be scarlatiniform. See the image below. Extensive blistering and sloughing on the back. Nondenuded areas have a wrinkled paper appearance. A Nikolsky sign is easily demonstrated by applying lateral pressure to a bulla. With regard to the arrangement of lesions, individual macules are found surrounding large areas (...) . In the study, the time from the onset of skin signs to arrest of disease progression and to complete reepithelialization was significantly shorter in the cyclosporine group. All patients in the cyclosporine group survived versus 50% surviving in the cyclophosphamide group. An open-label phase II trial of adults and a retrospective chart review of patients with Stevens-Johnson syndrome/toxic epidermal necrolysis treated with cyclosporine have also demonstrated a decrease in death and the progression

2014 eMedicine.com

68. Oral Manifestations of Autoimmune Blistering Diseases (Overview)

and immunopathologic findings usually are the same as that of human diseases and are not discussed here. Pemphigus group Pemphigus vulgaris is a very rare acantholytic skin disease. In most cases, oral involvement is severe, and the mouth sometimes can be the first site to exhibit lesions. Flaccid vesicles on the gums, tongue, and palate evolve rapidly into erosions and ulcerations with indistinct margins and peripheral sloughing of mucosal epithelium (Nikolsky sign). Pemphigus foliaceus, the most common form (...) Educate patients with autoimmune diseases about the nature of the disease and the possible adverse effects of long-term use of immunosuppressives. In addition, patients should know about the benefits of taking calcium and vitamin D supplements while using systemic corticosteroids. Finally, educate patients to monitor signs and symptoms of infection in order to report possible complications to physicians in a timely manner. Previous References Olivry T, Chan LS. Autoimmune blistering dermatoses

2014 eMedicine.com

69. Laser-Assisted Hair Removal (Overview)

by a polarized headlamp with a magnifying loupe (Seymour light). Treatment fluence: The ideal treatment parameters must be individualized for each patient; test sites can be placed at inconspicuous regions of the area to be treated. The fluence is carefully increased while observing the skin for signs of acute epidermal injury, such as whitening, blistering, ablation, or the Nikolsky sign (forced epidermal separation). In general, the treatment fluence should be at 75% of the Nikolsky threshold fluence (...) and duration of changes: The intensity and duration of these tissue changes depend on the hair color and density. The fluence should be reduced if signs of epidermal damage develop. Immediate reaction after laser impact (note erythema, mild edema, sizzling of hairs) Postoperative care Ice packs reduce postoperative pain and minimize swelling. Analgesics are not usually required unless extensive areas are treated. Prophylactic courses of antibiotics or antivirals should be completed. Topical antibiotic

2014 eMedicine.com

70. Drug Eruptions (Overview)

after drug withdrawal and any reaction with readministration Physical examination should address clinical features that may indicate a severe, potentially life-threatening drug reaction, including the following: Mucous membrane erosions Blisters Nikolsky sign Confluent erythema Angioedema and tongue swelling Palpable purpura Skin necrosis Lymphadenopathy High fever, dyspnea, or hypotension It is important to appreciate the morphology and physical features of drug eruptions, as follows: Acneiform (...) and who suddenly develops a symmetric cutaneous eruption. Morbilliform eruption localized to striae has been described with clindamycin. [ ] Morbilliform drug eruption. Signs and symptoms The first steps in the history are as follows: Review the patient’s complete medication list, including prescription and over-the-counter drugs Document any history of previous adverse reactions to drugs or foods Consider alternative etiologies (eg, viral exanthems and bacterial infections) Note any concurrent

2014 eMedicine.com

71. Fogo Selvagem (Treatment)

daily morning dose until blister formation ceases or the Nikolsky sign disappears. After initial control is achieved, the prednisone dose is reduced to about half the initial dose. This reduction is followed by slow tapering to the minimal effective maintenance dose over weeks to months. Adjuvant therapy includes the use of immunosuppressants such as azathioprine (1-2 mg/kg body weight until lesions clear; with slow tapering of dose), cyclophosphamide (100-200 mg qd, with a reduction (...) to therapy; however, this practice is not universal. Patients taking long-term steroids and/or immunosuppressants should be appropriately followed up and monitored. The lowest possible dose of steroids and immunosuppressants should be used to minimize the potential for systemic toxicities. Be aware of bacterial, viral, or fungal secondary infections and infestations. Disseminated strongyloidiasis is reported. Previous References Nikolsky PV. Materiali K. uchenigu o pemphigus foliaceus [doctoral thesis

2014 eMedicine.com

72. Pemphigus Foliaceus (Follow-up)

with pemphigus that is relatively resistant to systemic steroid therapy. [ ] Toth and Jonkman also reported on successful therapy with intravenous immunoglobulin (low dose). [ ] References Nikolski PV. Materiali K.uchenigu o pemphigus foliaceus [doctoral thesis]. Kiev . 1896. Chorzelski T, Jablonska S, Blaszczyk M. Immunopathological investigations in the Senear-Usher syndrome (coexistence of pemphigus and lupus erythematosus). Br J Dermatol . 1968 Apr. 80(4):211-7. . Jablonska S, Chorzelski TP, Beutner EH (...) Research. N Engl J Med . 2000 Jul 6. 343(1):23-30. . Fariba G, Ayatollahi A, Hejazi S. Pemphigus foliaceus. Indian Pediatr . 2012 Mar 8. 49(3):240-1. . Metry DW, Hebert AA, Jordon RE. Nonendemic pemphigus foliaceus in children. J Am Acad Dermatol . 2002 Mar. 46(3):419-22. . Daoud YJ, Foster CS, Ahmed R. Eyelid skin involvement in pemphigus foliaceus. Ocul Immunol Inflamm . 2005 Sep-Oct. 13(5):389-94. . Uzun S, Durdu M. The specificity and sensitivity of Nikolskiy sign in the diagnosis of pemphigus. J

2014 eMedicine.com

73. Percutaneous Transluminal Coronary Angioplasty (Follow-up)

) guidelines on the management of NSTE-ACS (updated in 2014 [ ] ) recommend an early invasive strategy in most cases, with timing as follows: Immediate (within 2 hours) - Patients with refractory angina, recurrent angina after initial treatment, signs/symptoms of heart failure, new/worsening mitral regurgitation, hemodynamic instability, sustained ventricular tachycardia, or ventricular fibrillation Early (within 24 hours) - None of the immediate characteristics but new ST-segment depression, a GRACE risk (...) Foundation/AHA guidelines for management of unstable angina/NSTEMI recommend the use of an early invasive strategy or ischemia-guided strategy in patients with NSTE-ACS. An ischemia-guided approach is recommended for patients with a low-risk score (TIMI 0 or 1, GRACE < 109). Other patients will benefit from an early invasive strategy stratified by timing as follows: Immediate (within 2 hours) - Patients with refractory or recurrent angina with initial treatment, signs/symptoms of heart failure, new

2014 eMedicine.com

74. Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis (Follow-up)

and bullae. Lesions, with the exception of central bullae, are typically flat. (Lesions of erythema multiforme are more likely to be palpable.) Less frequently, the initial eruption may be scarlatiniform. See the image below. Extensive blistering and sloughing on the back. Nondenuded areas have a wrinkled paper appearance. A Nikolsky sign is easily demonstrated by applying lateral pressure to a bulla. With regard to the arrangement of lesions, individual macules are found surrounding large areas (...) . In the study, the time from the onset of skin signs to arrest of disease progression and to complete reepithelialization was significantly shorter in the cyclosporine group. All patients in the cyclosporine group survived versus 50% surviving in the cyclophosphamide group. An open-label phase II trial of adults and a retrospective chart review of patients with Stevens-Johnson syndrome/toxic epidermal necrolysis treated with cyclosporine have also demonstrated a decrease in death and the progression

2014 eMedicine.com

75. Fogo Selvagem (Follow-up)

daily morning dose until blister formation ceases or the Nikolsky sign disappears. After initial control is achieved, the prednisone dose is reduced to about half the initial dose. This reduction is followed by slow tapering to the minimal effective maintenance dose over weeks to months. Adjuvant therapy includes the use of immunosuppressants such as azathioprine (1-2 mg/kg body weight until lesions clear; with slow tapering of dose), cyclophosphamide (100-200 mg qd, with a reduction (...) to therapy; however, this practice is not universal. Patients taking long-term steroids and/or immunosuppressants should be appropriately followed up and monitored. The lowest possible dose of steroids and immunosuppressants should be used to minimize the potential for systemic toxicities. Be aware of bacterial, viral, or fungal secondary infections and infestations. Disseminated strongyloidiasis is reported. Previous References Nikolsky PV. Materiali K. uchenigu o pemphigus foliaceus [doctoral thesis

2014 eMedicine.com

76. Staphylococcus Aureus Infection (Diagnosis)

. Gentle shearing forces on intact skin cause the upper epidermis to slip at a plane of cleavage in the skin, which is known as the Nikolsky sign. How the exfoliative toxins produce epidermal splitting has not been fully elucidated. [ ] The most feared manifestation of S aureus toxin production is . Although first described in children, it was most frequently associated with women using tampons during menstruation. Since the early 1990s, at least half of the cases have not been associated (...) recently, vancomycin-resistant strains. An example of radiographic findings in S aureus infections is shown in the image below. Posteroanterior chest radiograph of a 15-year-old with staphylococcal endocarditis and multiple septic emboli, revealing borderline cardiomegaly, multiple nodular infiltrates, and bilateral pleural effusions. Signs and symptoms Types and presentation of S aureus infection include the following: Skin and soft tissue (impetigo): A small area of erythema that progresses

2014 eMedicine Pediatrics

77. Staphylococcus Aureus Infection (Overview)

. Gentle shearing forces on intact skin cause the upper epidermis to slip at a plane of cleavage in the skin, which is known as the Nikolsky sign. How the exfoliative toxins produce epidermal splitting has not been fully elucidated. [ ] The most feared manifestation of S aureus toxin production is . Although first described in children, it was most frequently associated with women using tampons during menstruation. Since the early 1990s, at least half of the cases have not been associated (...) recently, vancomycin-resistant strains. An example of radiographic findings in S aureus infections is shown in the image below. Posteroanterior chest radiograph of a 15-year-old with staphylococcal endocarditis and multiple septic emboli, revealing borderline cardiomegaly, multiple nodular infiltrates, and bilateral pleural effusions. Signs and symptoms Types and presentation of S aureus infection include the following: Skin and soft tissue (impetigo): A small area of erythema that progresses

2014 eMedicine Pediatrics

78. Pemphigus Foliaceus (Diagnosis)

skin that blisters when rubbed (the Nikolsky sign; commonly but incorrectly spelled Nicholsky), a finding named after Dr Piotr Nikolsky, who first described this sign in 1896. [ ] Pemphigus foliaceus is characterized by a chronic course, with little or no involvement of the mucous membranes. Pierre Louis Alphee Cazenave, founder of the first journal dedicated entirely to dermatology, documented the first description of pemphigus foliaceus in 1844 in this journal. The description was of a 47-year (...) -old woman who consulted him at l'Hopital Saint Louis in Paris for a generalized eruption of several years' duration. Nikolsky described lateral extension of the preexisting erosion due to lifting up the collarette (and when applying a lateral pressure to the clinically intact skin), whereas Asboe-Hansen described extension of the intact blister due to pressure that is applied to its roof. Pemphigus foliaceus has the following six subtypes: pemphigus erythematosus (PE), pemphigus herpetiformis (PH

2014 eMedicine.com

79. Percutaneous Transluminal Coronary Angioplasty (Diagnosis)

) guidelines on the management of NSTE-ACS (updated in 2014 [ ] ) recommend an early invasive strategy in most cases, with timing as follows: Immediate (within 2 hours) - Patients with refractory angina, recurrent angina after initial treatment, signs/symptoms of heart failure, new/worsening mitral regurgitation, hemodynamic instability, sustained ventricular tachycardia, or ventricular fibrillation Early (within 24 hours) - None of the immediate characteristics but new ST-segment depression, a GRACE risk (...) Foundation/AHA guidelines for management of unstable angina/NSTEMI recommend the use of an early invasive strategy or ischemia-guided strategy in patients with NSTE-ACS. An ischemia-guided approach is recommended for patients with a low-risk score (TIMI 0 or 1, GRACE < 109). Other patients will benefit from an early invasive strategy stratified by timing as follows: Immediate (within 2 hours) - Patients with refractory or recurrent angina with initial treatment, signs/symptoms of heart failure, new

2014 eMedicine.com

80. Oral Manifestations of Autoimmune Blistering Diseases (Diagnosis)

and immunopathologic findings usually are the same as that of human diseases and are not discussed here. Pemphigus group Pemphigus vulgaris is a very rare acantholytic skin disease. In most cases, oral involvement is severe, and the mouth sometimes can be the first site to exhibit lesions. Flaccid vesicles on the gums, tongue, and palate evolve rapidly into erosions and ulcerations with indistinct margins and peripheral sloughing of mucosal epithelium (Nikolsky sign). Pemphigus foliaceus, the most common form (...) Educate patients with autoimmune diseases about the nature of the disease and the possible adverse effects of long-term use of immunosuppressives. In addition, patients should know about the benefits of taking calcium and vitamin D supplements while using systemic corticosteroids. Finally, educate patients to monitor signs and symptoms of infection in order to report possible complications to physicians in a timely manner. Previous References Olivry T, Chan LS. Autoimmune blistering dermatoses

2014 eMedicine.com

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