Rev Med Hosp Gen Méx.

2016;79(1):33---39

´
www.elsevier.es/hgmx

REVIEW ARTICLE

Dermatologic emergencies
M.P. Simón Díaz ∗ , A. Tirado Sánchez, R.M. Ponce Olivera

General Hospital of Mexico, Department of Dermatology, Mexico City, Mexico

Received 16 June 2015; accepted 3 September 2015

Available online 30 November 2015

KEYWORDS Abstract Dermatologic emergencies represent about 8---20% of the diseases seen in the
Dermatologic Emergency Department of hospitals. It is often a challenge for primary care physicians to dif-
emergencies; ferentiate mundane skin ailments from more serious, life threatening conditions that require
Stevens-Johnson immediate intervention. In this review we included the following conditions: Stevens-Johnson
syndrome/toxic syndrome/toxic epidermal necrosis, pemphigus vulgaris, toxic shock syndrome, fasciitis necro-
epidermal necrosis; tising, angioedema/urticaria, meningococcemia, Lyme disease and Rocky Mountain spotted
Pemphigus vulgaris; fever.
Toxic shock © 2015 Sociedad Médica del Hospital General de México. Published by Masson Doyma México
syndrome; S.A. All rights reserved.
Fasciitis necrotising;
Angioedema/urticaria;
Meningococcemia;
Lyme disease;
Rocky Mountain
spotted fever

PALABRAS CLAVE Urgencias dermatológicas

Urgencias
dermatológicas; Resumen Las enfermedades dermatológicas representan del 8% al 20% de la consulta en el
Síndrome de Servicio de Urgencias de los hospitales. Para el médico de primer contacto constituye un reto
Stevens-Johnson el diferenciar enfermedades leves de aquellas que ponen en peligro la vida y requieren inter-
(SSJ)/necrolisis vención inmediata. De estas existen múltiples que pueden ser potencialmente fatales y otras
epidérmica tóxica que requieren ser evaluadas por el especialista. En esta revisión se incluyen las siguientes
(NET);

∗ Corresponding author at: General Hospital of Mexico, Department of Dermatology, Dr. Balmiz 148, Colonia Doctores, Delegación Cuauhte-

moc, 06726 Mexico City, Mexico. Tel.: +52 5 55 27892000.

E-mail address: pilarsimond@gmail.com (M.P. Simón Díaz).

http://dx.doi.org/10.1016/j.hgmx.2015.09.004
0185-1063/© 2015 Sociedad Médica del Hospital General de México. Published by Masson Doyma México S.A. All rights reserved.
34 M.P. Simón Díaz et al.

enfermedades: Síndrome de Stevens-Johnson (SSJ)/necrolisis epidérmica tóxica (NET), pénfigo

Pénfigo vulgar; vulgar (PV), síndrome de choque tóxico (SST), fascitis necrotizante (FN), angioedema/urticaria,
Síndrome de choque meningococcemia, enfermedad de Lyme y Fiebre Macular de las Montañas Rocosas (FMMC).
tóxico (SST); © 2015 Sociedad Médica del Hospital General de México. Publicado por Masson Doyma México
Fascitis necrotizante; S.A. Todos los derechos reservados.
Angioedema/urticaria;
Meningococcemia;
Enfermedad de Lyme;
Fiebre Macular de las
Montañas Rocosas

Introduction

Between 8% and 20% of patients seen in hospital emer-

gency departments present with dermatological diseases.1,2
Differentiating between mild and life-threatening condi-
tions that required immediate treatment can be challenging
for doctors in charge of the preliminary assessment of
the patient.2 Many dermatological disease can be fatal
and must be evaluated by a dermatologist, intensivist,
surgeon, or other specialist.3 In this review, we will
focus on the following diseases: Stevens-Johnson Syndrome
(SJS)/Toxic epidermal necrolysis (TEN), pemphigus vulgaris
(PV), toxic shock syndrome (TSS), necrotising fasciitis (NF),
angiooedema/urticaria, meningococcaemia, Lyme disease
and Rocky Mountain spotted fever (RMSF). Some of these
entities require aggressive hospital treatment and must be
diagnosed immediately. Others should be referred to a spe- Figure 1 Toxic epidermal necrolysis.
cialist for watchful waiting to prevent potentially severe or
incapacitating complications. characterised by ulceration of the skin, necrosis and severe
systemic alterations affecting the lungs, the cardiovascu-
lar and gastrointestinal systems, the kidneys and blood.
Stevens-Johnson Syndrome/Toxic epidermal Patients can present with anaemia, leukopaenia, hepatitis,
necrolysis (SJS/TEN)

These are part of a spectrum of life-threatening, drug-

induced mucocutaneous diseases. The drugs most frequently
involved are allopurinol, aniconvulsants such as pheny-
toin and carbamazepine, non-steroidal anti-inflammatory
drugs, sulphonamides and beta-lactams.3 Incidence is esti-
mated at between 0.4% and 7% per million inhabitants,
irrespective of age group or sex. SJS/TEN is characterised
by prodromal symptoms such as general malaise, rhinitis,
odynophagia, conjuctivitis, myalgia and arthralgia, which
can last up to 2 weeks. During this time, a macular rash
with or without atypical target lesions appears, usually in
truncal areas, and then extends to the extremities. Bullae
also form, sometimes accompanied by denuded areas with
a positive Nikolsky’s sign (Toxic epidermal necrolysis).3---6
(Figs. 1 and 2). Mucous membrane involvement is found
in 70---100% of cases, with inflammation, pain and severe
ulceration that can progress to involve the oesophageal
and tracheal mucosa, thus increasing the risk of respira-
tory failure.3,5 Nearly all patients have ocular and genital
involvement. TEN is believed to be severe form of SJS, where
severity is measured by the extent of body surface area
(BSA) involvement. In SJS, <10% of total BSA is involved,
while in TEN this increases to >30%. Between 10% and 30%
of cases are considered to involve SJS/NET overlap.3 NET is Figure 2 Toxic epidermal necrolysis.
Dermatologic emergencies 35

severe abdominal pain, hypoalbuminaemia, hyponatraemia,

encephalopathy and myocarditis.5 Diagnosis is based on
clinical and histological findings. The main skin findings
include erythema, erythematous or violaceous spots and
morbilliform or atypical target lesions, which progress to
bullae formation, epidermal detachment and even necrosis.
Patients report a recent history of constitutional symp-
toms such as fever, general malaise and anorexia. Mucosal
involvement is found in nearly all cases. Histology find-
ings include full thickness epidermal necrosis, separation
at the dermoepidermal junction, CD4+ T lymphocyte infil-
trates in the dermis and CD8+ T lymphocyte infiltrates in
the epidermis. Complications include hypotension, kidney
failure, corneal ulcers, anterior uveitis, erosive vulvovagini-
tis or balanitis, respiratory failure, seizures and coma. The
most common sequelae are ocular scars and blindness.4 The
mortality rate ranged from 25% to 30%, and can be due to
a number of causes, the most common being sepsis. The
SCORTEN (SCORe of Toxic Epidermal Necrosis) (Table 1) scale Figure 3 Pemphigus vulgaris.
was developed to assess the severity of the disease and
predict a fatal outcome in patients with acute TEN. The therapy such as systemic steroids, intravenous immunoglob-
scale consists of 7 variables, each scoring 1 point: (1) age ulin, cyclosporine, ␣ tumour necrosis factor inhibitors
>40 years; (2) heart rate >120 bpm; (3) associated malig- (TNF-␣) and N-acetylcysteine in NET, and these must be used
nancy; (4) Detached or compromised body surface >10%; at the discretion of the attending physician.7
(5) serum blood urea nitrogen >28 mg/dL; (6) serum glu-
cose >252 mg/dL; and (7) serum bicarbonate <20 mEq/L. Risk Pemphigus vulgaris (PV)
of mortality increases by 3.2% in patients with a score of
0---1 points, by 35.3% in patients scoring 3 points, and up PV continues to be associated with significant morbid-
to 90% in patients with a score of ≥5.7 Supportive strate- ity. Annual incidence of the disease is 0.42 per 100,000
gies include identifying and discontinuing administration inhabitants, and is most common in people between the
of the causative drug, admission to a burn unit or inten- ages of 40 and 60 years. PV is a blistering skin disease
sive care unit, if necessary, administration of intravenous in which between 50% and 70% of patients present with
liquids, maintaining electrolyte and temperature homeosta- painful oral lesions. The primary eruption consists of flaccid
sis, and ophthalmologic assessment in the case of occular blisters that easily rupture leaving painful, superficial
involvement. Skin lesions should be treated with appropriate erosions on the oral epithelium, lips and palate. This can
dressing; antihistamines and steroids are given for pruritus, be followed by flaccid blisters on seemingly healthy skin,
and antimicrobial therapy will be rendered in cases of super- with a positive Nikolsky’s sign, which rapidly progress to
infection due to skin-barrier breakdown. Additional therapy painful erosions, predominantly on the scalp, truncal area,
consists of ocular lubrication, ophthalmic cyclosporine, and and often on the face and neck (Figs. 3 and 4). The areas of
antiseptics for oral hygiene.2 There is insufficient evi- erosion can be large, painful, and prone to bleeding. Other
dence in the literature to recommend adjuvant systemic areas of involvement include the oesophageal, laryngeal,
nasopharyngeal, vaginal and rectal mucosa. Diagnosis is
based on clinical signs and direct immunofluorescence
Table 1 Severity of illness score for toxic epidermal assay.3,8 Histopathology findings include suprabasilar
necrolysis.
Criteria: Each variable scores 1 point

Age >40 years

Heart rate >120 beats per minute
Associated malignancy
Detached or compromised body surface >10% in 1 day
Serum blood urea nitrogen >28 mg/dL
Serum glucose >252 mg/dL
Serum bicarbonate <20 mEq/L
Total score (predicted mortality)
0---1 (3.2%)
2 (12.2%)
3 (35.5%)
4 (58.3%)
≥5 (90%)
Data from Swartz et al. Figure 4 Pemphigus vulgaris.
36 M.P. Simón Díaz et al.

bullae with predominantly neutrophilic and eosinophilic progress to hypotension and organ failure. Diagnosis of TSS is
inflammatory infiltrate. Direct immunofluorescence shows based on both clinical signs and culture of body fluids. How-
immunoglobulin G (IgG) and complement (C3) deposition on ever, the presence or absence of bacteria will not affect
cell surfaces, giving the characteristic ‘‘honeycomb’’ pat- prognosis. Mortality associated with streptococcal TSS is
tern’’.8,9 Patients with extensive lesions should be admitted much higher than with staphylococcal TSS, and can be as
to a specialised dermatology ward, and multidisciplinary high as 80% in association with myositiss.13 Aggressive sup-
management is sometimes required. Treatment consists of portive management is required to treat hypotension and
topical steroids for early oral lesions and systemic steroids potential multi-organ failure.2 Antibiotic treatment with ␤-
for extended disease. These can be combined with adjuvant lactams and lincosamides is recommended while awaiting
immunosuppressive therapy from the outset, particularly the results of specimen culture.13
in patients at high risk due to steroid therapy. They can
also be combined with first-line drugs such as azathioprine Necrotising fasciitis
(1---3 mg/kg/day) or mycophenolate mofetil (2 g/day) or
mycophenolic acid (144 mg/day).10---12 Supportive therapy Necrotising fasciitis (NF) is a potentially fatal soft-tissue
consists of antiseptic dressings, analgesics, nutritional infection characterised by extensive necrosis of the superfi-
management and evaluation by a gastroenterologist. PV can cial fascia. Onset is insidious, and the disease progresses
cause permanent sequelae, not only from skin and mucosal rapidly. NF can arise after a skin lesion or through
lesions, but also from the side effects of treatment. Poor haematogenous dissemination. Around 50% of cases involve
prognosis factors in patients with PV include: onset before young adults. Infection can be polymicrobial or caused by a
40 years of age, ethnic origin (Sephardic Jews), mucosal single pathogen, most frequently Streptoccocus pyogenes.
involvement, and poor response to treatment.13 Evolution is Polymicrobial NF is typically caused by a mixture of anaero-
chronic, and without prompt treatment mortality rates can bic and facultative organisms that act in synergy to cause
be as high as 50%, usually due to secondary sepsis. Mortality initial symptoms that can be mistaken for cellulitis. As
fell to 10% after the introduction of systemic steroids.3 the disease progresses, infectious organisms proliferate and
spread from the subcutaneous tissue along the superficial
and deep fascial planes. Enzymes and bacterial toxins are
Toxic shock syndrome (TSS) pivotal to the infection, as exotoxins bind the T-cell recep-
tors triggering excessive cytokine secretion, which is a factor
Toxic shock syndrome is an acute, multi-system, toxin- in organ failure and septic shock syndrome.14 Preliminary
mediated illness, often resulting in shock and multi-organ skin findings in streptococcal NF are diffuse oedema of the
failure early in its course. It represents the most ful- affected area, severe pain, fever and chills. This is followed
minant expression of a spectrum of diseases caused by by the appearance of haemorrhagic bullae; as infection pro-
toxin-producing strains of Staphylococcus aureus and Strep- gresses painless ulcers develop. If not treated promptly, the
tococcus pyogenes (group A streptococcus [GAS]). It has an patient will develop eschar, vascular occlusion, ischaemia
incidence of 1---5 per 100,000 inhabitants. It can result from and tissue necrosis (Figs. 5 and 6). Findings of hypotension,
primary S. aureus infection in women who use tampons tachycardia, pain disproportionate to the obvious lesion and
during their menstrual period, or in patients with infected local crepitus are signs and symptoms that should raise sus-
surgical wounds. When it is caused by S. pyogenes it is picion of NF. Rapid disease progression and poor response
secondary to soft-tissue infections, with a mortality rate to treatment in a patient diagnosed with cellulitis, with
of 30%. TSS is found at the extremes of age, and mortal- tachycardia and altered mental state also suggest NF. It is
ity is greater among patients with comorbidities, patients important to rule out urticaria, as both entities are clin-
recovering from varicella infection, and those taking non- ically similar (Table 2).2,13,15 Diagnostic likelihood can be
steroidal anti-inflammatory drugs.13 The toxins released by established on the basis of the Laboratory Risk Indicator
these bacteria trigger massive cytokine secretion by T lym- for Necrotising Fasciitis (LRINEC). In this system, a score
phocytes, leading to hypotension and multiorgan failure.
TSS secondary to S. aureus infection presents after a 2---3-
day prodromal illness consisting of fever, chills, nausea
and abdominal pain. This is followed by the appearance
of a generalised, nonpruritic maculopapular or petechial
rash. Desquamation is a characteristic late feature. Signs
appear initially in truncal areas and extend outwards to
affect the soles and palms. Multiorgan failure consists of
arrhythmia, kidney and liver failure, disseminated intravas-
cular coagulation and acute respiratory distress syndrome
.2 Streptococcal toxic shock syndrome is usually triggered
by soft tissue infection such as necrotising fasciitis, cel-
lulitis, and myositis. Patients present with a prodromal
illness involving fever, odynophagia, enlarged lymph glands
and abdominal pain. The initial lesion not be evident, and
can present as a blunt trauma, haematoma, muscle strain
or joint effusion. Examination may reveal rash, haemor-
rhagic bullae, skin sloughing, and oedema. Patients rapidly Figure 5 Necrotising fasciitis.
Dermatologic emergencies 37

Table 3 Laboratory Risk Indicator for Necrotising Fasciitis

(LRINEC).

Criteria Score
C reactive protein (mg/L)
<150 0
>150 4
White blood cells (mm3 )
<15,000 0
15---25,000 1
>25,000 2
Haemoglobin (g/dL)
>13.5 0
11---13.5 1
<11 2
Figure 6 Necrotising fasciitis.
Sodium (mmol/L)
≥135 0
of ≥6 raises suspicion of NF, while a score of ≥ is highly <135 2
predictive of the disease (Table 3).16 Plain radiography can
Creatinine (mg/dL)
reveal the presence of gas in soft tissue. Computed tomogra-
≤1.6 0
phy is more sensitive in the detection of subcutaneous gas,
>1.6 2
and magnetic resonance imaging (MRI) can define the exten-
sion of the disease and is also useful in guiding emergency Glucose (mg/dL)
surgical debridement. The sensitivity of MRI, however, is ≤180 0
marred by its lack of specificity.14 Prompt diagnosis, aggres- >180 1
sive management of the infection and surgical debridement
of necrotic tissue are essential for effective treatment of
NF. Antibiotics suitable for streptococcal infection should anaphylaxis or anaphylactic shock, mainly mediated by
be administered. Wide spectrum antibiotics should be used immunoglobulin E (IgE). Acute urticaria and angiooedema
when the causal agent cannot be identified. Intravenous are usual self-limiting. However, mucocutaneous airway
immunoglobin can be a beneficial concomitant treatment to inflammation can be life-threatening in itself, or can be
neutralise superantigens and reduce TNF-␣ and IL-6 levels.2 a contributing factor in anaphylactic shock. Urticaria is
characterised by pruritic rash that can appear on any part of
Angiooedema and urticaria the body. These manifestations last only a few hours while
new lesion appears in other areas.17 Angiooedema is char-
Drug hypersensitivity reactions are difficult to predict and acterised by well-circumscribed areas of oedema caused by
can be life-threatening. This type of reaction is charac- increased vascular permeability. It most frequently involves
terised by the appearance of symptoms within 1 h following the skin and the gastrointestinal and respiratory tracts.
administration of the drug. Patients usually present Patients typically present subcutaneous oedema, generally
with urticaria, angiooedema, rhinitis, bronchospasm, on the face, extremities and genitals. Unlike a rash, which
is pruritic, the oedema is accompanied by burning pain
and sensation of pressure at the site of the swelling. In
Table 2 Differential diagnosis between necrotising fasciitis contrast to urticaria, angiooedema can persist for several
and cellulitis. days.2,17 Urticaria can be associated with angioedema
in 50% of cases. Although often idiopathic, angioedema
Necrotising fasciitis Cellulitis can be induced by medications, allergens, or physical
Severe pain (dis- Yes No agents.2 Typically, 10---25% of cases are due to angiotensin-
proportional) converting-enzyme (ACE) inhibitor therapy, which occurs in
Areas of Yes No 1---2 per 1000 new users. In these cases, it is not associated
anaesthesia with urticaria, and the angiooedema is asymmetrical
Presence of bullae Yes No and lasts between 24 and 48 h17 Penicillins, nonsteroidal
Toxic patient with Yes No anti-inflammatory drugs (NSAID) and radiographic contrast
systemic media are other important triggers. Angioedema can occur
involvement as a result of C1 (INHC1 ) esterase inhibitor deficiency.
Poor response to Yes No Two rare but well-described categories exist: hereditary
treatment angioedema, which is transmitted in autosomal-dominant
Imaging studies Yes No fashion; and acquired angioedema, which can be associated
show air in with autoimmune disorders and B-cell lymphoproliferative
tissues malignant disease.2,18 The skin is involved in 90% of cases
of anaphylactic shock (urticaria and/or angiooedema).
38 M.P. Simón Díaz et al.

Other organs involved include the upper respiratory tract endemic to Europe and Asia, is a cutaneous manifestation of
(inflammation of the tongue and larynx), lower respiratory the disease in which patients present multiple EM plaques.
tract (dyspnoea, wheezing, hypoxaemia), gastrointestinal Stage 3 is characterised by encephalopathy and chronic
tract (nausea, vomiting, diarrhoea and abdominal pain) arthritis. Skin manifestations are rare at this stage. Around
and the cardiovascular system (dizziness, hypotension and 50% of adults and 90% of children present EM, which is char-
syncope) in around 30% of patients.17 Treatment is largely acterised by an erythematous macule at the site of entry
supportive. Airway patency must be ensured. Cool, moist which spreads to form a circular macule measuring between
compresses and antihistamines can be used to control local 5 and 50 cm in diameter (mean 13 cm). As it disseminates,
burning. Referral to an allergy specialist for appropriate the macule takes on the typical bull’s eye pattern.22,23 The
investigations should be considered. presence of multiple EM lesions, which can occur simulta-
neously or sequentially, is typical of stage 2 of the disease.
Systemic involvement can occur even in the absence of
Meningococcaemia
obvious lesions. When multiple lesions occur, they usually
take the form of small, ring-shaped rashes. Acrodermati-
Meningococcaemia is a leading cause of meningitis in the
tis chronica atrophicans (ACA) is a chronic manifestation
paediatric population. It is caused by Neisseria meningitidis,
that can appear months or even years after infection. It
and incidence is estimated at 1.1 cases per 100,000 inhabi-
manifests as erythematous plaques on the arms and legs,
tants. It affects children and adolescents, with incidence
which progress to form atrophic, hyperpigmented lesions.
peaking in infants aged 6---12 months. The classic presen-
The disease is associated with neuropathy in 60% of cases,
tation of meningococcaemia is maculopapular or petechial
mainly allodynia.21 Early diagnosis is essential to prevent
rash and fever, chills, malaise and disorientation.2,3 Rash
systemic involvement. The need for diagnostic tests in areas
is a pathognomonic sign of the disease, starting with ten-
where Lyme disease is not endemic is controversial. In
der skin followed by erythema, which is hard to distinguish
asymptomatic patients presenting with tick bite, watchful
from a viral rash. These signs are followed by petechiae on
waiting for 30 days is the best approach.22,24 Stage 1 treat-
the wrists, ankles and axillae, which spreads to the head,
ment consists of a 3-week course of 100 mg doxycycline
palms and soles. Within a few hours, these progress to form
every 12 h.22,25 Intravenous antibiotic therapy is needed in
a purpuric rash, followed by thrombolysis with perivascular
advanced stages with neurological complications, atrioven-
bleeding. The disease rapidly progresses to septic shock,
tricular block and meningitis. Although it does not meet the
disseminated intravascular coagulation, shock and death.3
criteria for a medical emergency, early diagnosis of Lyme
Meningococcaemia should be suspected in all patients, par-
disease is essential to prevent complications.3
ticularly children, presenting with petechial rash and fever,
and blood, cerebrospinal fluid (if not contraindicated), nee-
dle aspiration and skin biopsy should be draw for culture Rocky Mountain spotted fever
to confirm a bacterial pathogenesis.20 Besides supportive
management, therapy with a third-generation cephalosporin Rocky Mountain spotted fever (RMSF) is a potentially
or intravenous penicillin G2 therapy should be started. life-threatening disease that is usually transmitted to
Cefotaxime (80 mg/kg) or ceftriaxone (80 mg/kg) are the humans through tick bites carrying the bacterium Rick-
treatments of choice for initial management of patients ettsia rickettsii.2 Cases of RMSF have been reported in the
in shock with a clinical diagnosis of meningococcemia. north and south of Mexico.26 It is associated with a mor-
The foregoing therapies can be complemented with sys- tality of 3---7% among treated patients and 30---70% among
temic dexamethasone to reduce brain damage, although it those not treated promptly or adequately. In about 60%
is contraindicated in meningococcal septic shock without of cases, patients present with a triad of fever, headache
meningitis19 Chloramphenicol can be used in patients with and rash following a tick bite. The purpuric macules and
penicillin allergy.2 Patients with persistent shock or signs papules typical of this condition appear within the first 2
of raised intracranial pressure should be transferred to an weeks on the wrists and ankles. They rapidly spread to the
intensive care unit.20 palms and soles and eventually to the trunk and face. Mul-
tiorgan involvement may lead to a variety of symptoms.
Complications of RMSF include peripheral oedema due to
Lyme disease
hepatic failure and hypoalbuminemia, myocarditis and car-
diogenic shock, acute kidney failure, altered mental state,
Lyme disease is caused by Borrelia burgdorferi, which is
seizures or coma, meningismus and disseminated intravascu-
transmitted to humans by 2 species of tick, Ixodes scapularis
lar coagulation. Besides symptomatic support, appropriate
and Ixodes pacificus after passing through a host reservoir,
treatment with doxycycline, the antibiotic drug of choice,
such as deer or mice.3 The disease progresses in 3 stages.
should be initiated immediately and continued for 3 after
Stage 1 (localised) appears 7---10 days after infection and is
resolution of fever and clinical improvement.27 The tick
characterised by erythema migrans (EM) at the site of infec-
should be removed if embedded in the skin at the time of
tion. Patients develop local lymphadenopathy, and around
presentation.2
60% present constitutional symptoms, such as fever, myal-
gia, arthralgia, malaise, headache and fatigue. In stage 2,
the disease spreads to the central nervous (CNS), muscu- Conclusions
loskeletal, and cardiovascular systems. Dissemination occurs
within days or up to months after the initial infection. Borre- Many dermatological diseases are potentially life-
lial lymphocytoma, which is caused by Borrelia afzelii and is threatening, and it is imperative that emergency physicians
Dermatologic emergencies 39

are able to differentiate between mild conditions and life- 11. Hertl M, Jedlickova H, Karpati S, et al. Phemphigus. S2
threatening diseases that require immediate intervention. Guideline for diagnosis and tratment-guided by the European
In this review, we have described the principle dermatologic Dermatology Forum (EDF) in cooperation with the European
diseases that can be potentially fatal. However, there are Academy of Dermatology and Venerealogy (EADV). JEADV. 2014:
many more, less common diseases that can be classified as 1---9.
12. Amagi M, Tanikawa A, Shimizu T, et al. Japanese guide-
dermatologic emergencies, such as loxoscelism, mucormy-
lines for the managment of pemphigus. J Dermatol. 2014;41:
cosis, cutaneous amebiasis, and so on, in which input from 471---86.
the dermatologist is a key element in diagnostic suspicion. 13. Mimouni D. Pemphigus, analysis of 155 patients. JEADV.
2010;24:947---52.
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Lancet Infect Dis. 2009;9:281---90.
The authors declare that they have no conflict of interests. 15. Kihiczak GG, Schwartz RA, Kapila R. Necrotizing fasciitis: a
deadly infection. JEAD. 2006;20:365---9.
16. Hirschmann J, Raugi G. Lower limb cellulitis and its mimics:
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