Rosen & Barkin's 5-Minute Emergency Medicine Consult (636 page)

• Severe neurologic deficit (cauda equina syndrome, inability to walk)
  
• Progressive neurologic deficit
  
• Multiple root involvement
  
• Unstable fracture, infection, neoplasm
  
• Inability to manage as outpatient (social situation/pain)
  

Patient able to ambulate, follow instructions, has reliable home situation and planned follow-up

Abnormal workup that does not warrant immediate admission. Where and when depend on results (large DDX)

• Consultant (orthopedic spine surgeon or neurosurgeon) or PCP within 1 wk
  
• Conservative treatment (4–6 wk):
  
  • Medication as noted
    
  • Avoid complete bed rest, 2 days at most
    
  • Limited activity in acute phase but gradually increase activity/exercise as tolerated
    
  • Avoid movements that load lower back or exacerbate pain:
    
    • Heavy lifting, twisting, bending, stooping, bodily vibration
      
• Therapies of unproven benefit:
  
  • Chiropractic care
    
  • Transcutaneous electrical nerve stimulation
    
  • Traction
    
  • Back brace/corset
    
  • Ultrasound
    
  • Diathermy
    
  • Acupuncture, acupressure
    
  • Massage
    
  • Systemic glucocorticoids
    

• Haas M, Sharma R, Stano M. Cost-effectiveness of medical and chiropractic care for acute and chronic low back pain.
  J Manipulative Physiol Ther
  . 2005;28(8):555–563.
  
• Jegede KA, Ndu A, Grauer JN. Contemporary management of symptomatic lumbar disc herniations.
  Orthop Clin North Am.
  2010;41(2):217–224.
  
• Schoenfeld AJ, Weiner BK. Treatment of lumbar disc herniation: Evidence-based practice.
  Int J Gen Med.
  2010;3:209–214.
  
• Tarulli AW, Raynor EM. Lumbosacral radiculopathy.
  Neurol Clin
  . 2007;25:387–405.
  
• van der Windt DA, Simons E, Riphagen II, et al. Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain.
  Cochrane Database Syst Rev
  . 2010;(2):CD007431.
  

CODES

• 722.10 Displacement of lumbar intervertebral disc without myelopathy
  
• 724.3 Sciatica
  
• 724.4 Thoracic or lumbosacral neuritis or radiculitis, unspecified
  

BASICS

• A common and chronic papulosquamous inflammatory skin disorder
  
• Affects all age groups and varies from mild dandruff to extensive adherent scale
  
• Found in areas with high concentrations of sebaceous follicles and glands
  
• Sharply demarcated yellow to red to brown, greasy, scaling, crusting patches/plaques
  
• Periods of remission and exacerbation frequent in adults
  

• Exact pathogenesis not fully understood
  
• Multifactorial with environmental, genetic, hormonal, immunologic, microbial, and nutritional influences
  
• Strong association with
  Malassezia
  yeasts
  
• Complex physiologic response:
  
  • Immunologic
    
  • Inflammatory
    
  • Hyperproliferation
    
• Disease flares are common with physical and emotional stresses or illness
  
• Factors predisposing patients to develop seborrheic dermatitis and more severe or refractory disease:
  
  • Parkinson disease
    
  • Paralysis
    
  • HIV/AIDS
    
  • Mood disorders including depression
    
  • Congestive heart failure
    
  • Immunosuppression in premature infants
    
• Medications known to induce or aggravate seborrheic dermatitis include:
  

DIAGNOSIS

• Onset during 1st few weeks of life, is usually self-limited and resolves by 12 mo of age
  
• May present concurrently with atopic dermatitis
  
• Flexural fold involvement may appear as diaper dermatitis:
  
  • Frequently develops a bacterial or fungal superinfection
    
• Cradle cap:
  
  • Thick greasy, adherent scale concentrated on the vertex of the scalp
    
  • Affects up to 70% of newborns during the 1st 3 mo of life
    
  • May be accompanied by inflammation or secondary infection
    

• Blepharitis:
  
  • White scale adherent to eyelashes and eyelid margins with erythema
    
  • Resistant to treatment and persistent
    
  • May result in blepharoconjunctivitis
    

• Classic seborrheic dermatitis:
  
  • Minor itching with greasy, fine, dry, white scaling overlying red, inflamed skin
    
• Exacerbated by avoidance of washing
  
• Usually bilateral, symmetrical, and favoring the following areas:
  
  • Scalp, forehead, eyebrows, eyelids
    
  • Areas of facial hair
    
  • External ear canals
    
  • Nasolabial and posterior auricular folds
    
  • Posterior neck
    
  • Presternal, navel, and body folds:
    
    • Axillary and inframammary regions
      
    • Groin and anogenital regions
      
• May cause areas of hypopigmentation in dark-skinned individuals
  

Diagnosis is based on clinical history and physical exam

• Potassium hydroxide preparations of skin scrapings may suggest yeast involvement
  
• Fungal culture may help to exclude dermatophytosis as an alternate diagnosis
  

None required

Skin biopsy (rarely required):

• May help to exclude other diagnoses
  
• Consider, if the diagnosis remains unclear or the condition fails to respond to treatment
  

• Atopic dermatitis:
  
  • Later onset in infants (usually >3 mo)
    
  • Characteristically affects antecubital and popliteal fossa in adults
    
  • Pruritus, oozing, and weeping support the diagnosis of atopic dermatitis
    
  • Family history of atopy (asthma and allergic rhinitis) favors atopic dermatitis
    
  • Axillary involvement favors the diagnosis of seborrheic dermatitis
    
• Contact dermatitis:
  
  • Polymorphous with erythema, edema, and vesicles
    
  • Tends to spare skin folds
    
  • May complicate seborrheic dermatitis as an unwanted reaction to treatment agents
    
• Cutaneous candidiasis:
  
  • Primary or secondary infection of the skin by
    Candida
    fungus
    
  • May affect any body area
    
  • Pruritus, erythema, mild scaling, and occasional blistering
    
  • Often associated with diabetes, obesity, or other illness
    
  • Common in infants
    
  • Presence of pseudohyphae on cytologic exam with potassium hydroxide does not exclude seborrheic dermatitis
    
• Dermatophytosis:
  
  • Generally distributed asymmetrically
    
  • Tinea capitis (scalp), corporis (body), cruris (groin), barbae (facial hair), faciei (face)
    
  • Can be very difficult to distinguish from seborrheic dermatitis
    
  • Hyphae on cytologic exam with potassium hydroxide is suggestive of tinea
    
• Langerhans cell histocytosis:
  
  • Systemic signs (e.g., fever and adenopathy)
    
  • Infants affected may display scaling
    
  • Reddish-brown papules or vesicles
    
  • Associated splenomegaly
    
  • Purpuric lesions
    
• Leiner disease:
  
  • Prevalent in infant females
    
  • Rapid onset in 2nd to 4th month of life
    
  • Deficiencies of complement C3, C5
    
  • Severe generalized, exfoliative, erythrodermic form of seborrheic dermatitis
    
  • Fever, anemia, diarrhea, vomiting, weight loss, and failure to thrive
    
• Lupus erythematosus:
  
  • Erythematous malar rash of the nose and malar eminences
    
  • Chronic or discoid lupus:
    
    • Discrete erythematous papules/plaques
      
    • Thick adherent scale
      
    • “Carpet tack” appearance if removed
      
• Psoriasis:
  
  • Thicker plaques with silvery white scales
    
  • Less likely confined to scalp
    
• Rosacea:
  
  • Usually with central facial erythema or forehead involvement
    
• Tinea versicolor (pityriasis versicolor):
  
  • Chronic superficial fungal disease usually located on the neck, upper arms, and trunk
    
  • Characterized by fine, scaly, coalescing, hypopigmented or hyperpigmented macules
    
  • Patient usually asymptomatic
    
  • Also associated with
    Malassezia
    yeast
    
    • Not a dermatophyte
      
  • Short, thick hyphae with spores (spaghetti-and-meatball pattern) seen on cytology with potassium hydroxide