Time sensitive infection escalation over imaging delays
CT
CT indications
Suspected necrotizing infection
Suspected deep abscess not defined by ultrasound
CT considerations
Contrast allergy history
Renal dysfunction and contrast risk
Ultrasound
POCUS applications
Abscess versus cellulitis differentiation
Guidance for incision and drainage when indicated
Ultrasound limitations
Early necrotizing infection can appear nonspecific
Deep compartment disease may be missed
Special Tests
Bedside dermatologic tests
Rapid bedside diagnostics
KOH prep
Dermatophyte hyphae support tinea
False negative with inadequate scraping
Dermoscopy
Scabies mite or burrow features
Limited availability and operator dependence
Microbiology sampling
Infection directed testing
Bacterial culture
Purulence
Recurrent infection
HSV PCR from lesion
Eczema herpeticum concern
Early treatment should not wait for result
Allergy evaluation
Contact allergy confirmation
Patch testing
Best for delayed hypersensitivity
Performed outpatient when stable
Ingredient review
Product labels and safety data sheets
Cross reactivity awareness
ECG
When ECG matters in this presentation
Indications for ECG
Anaphylaxis with hypotension or chest symptoms
Significant tachycardia
Medication related considerations
QT prolongation risk factors
Electrolyte abnormalities with severe illness
Assessment
Working diagnosis framework
Working diagnosis options
Allergic contact dermatitis (L23.9)
Clear exposure and distribution match
Delayed onset after exposure
Irritant contact dermatitis (L24.9)
Wet work and irritants
Burning and fissuring
Atopic dermatitis flare (L20.9)
Chronic relapsing history
Flexural or diffuse xerosis
Severity stratification
Severity features
Body surface area involvement
Sleep disruption
Facial or genital involvement
Secondary infection concern
Complications to rule out
Complications
Impetigo (L01.00)
Cellulitis (L03.90)
Eczema herpeticum (B00.0)
SJS or TEN (L51.1)
Plan
Approach to the critical patient
First 5 minutes
Escalation triggers
Airway compromise
Hypotension
Rapidly progressive rash with systemic symptoms
Immediate actions
Cardiorespiratory monitoring
IV access if unstable
Remove trigger and supportive skin care
Trigger control and barrier repair
Discontinue suspected product exposure
Gentle cleanser fragrance free
Emollient thick ointment or cream multiple times daily
Topical anti inflammatory therapy
Topical corticosteroids
Low potency
Face and intertriginous areas
Example hydrocortisone 1 percent to 2.5 percent topical thin layer 1 to 2 times daily up to 7 to 14 days
Medium potency
Trunk and extremities
Example triamcinolone 0.1 percent topical thin layer 1 to 2 times daily up to 14 days
High potency
Thick plaques on palms or soles
Avoid face groin axilla
Topical calcineurin inhibitors
Tacrolimus 0.1 percent topical to face or eyelids 1 to 2 times daily
Pimecrolimus 1 percent topical to sensitive areas 1 to 2 times daily
Pruritus control
Anti itch strategies
Non sedating antihistamine
Cetirizine 10 mg PO daily
Loratadine 10 mg PO daily
Nighttime itch with sleep disruption
Diphenhydramine 25 to 50 mg PO at bedtime
Sedation and anticholinergic cautions
Non pharmacologic
Cool compress
Short nails
Cotton clothing
Wet wrap and occlusion strategies
Adjunctive therapy for moderate to severe flares
Wet wrap therapy
After emollient and prescribed topical
Limited duration to reduce maceration
Occlusion
Short term for hands and feet
Avoid if infection suspected
Systemic therapy and escalation
Systemic therapy considerations
Systemic corticosteroid use
Prefer avoid in routine atopic dermatitis due to rebound risk
Consider short course only for severe allergic contact dermatitis with extensive involvement and no infection concern
Biologics and advanced therapy referral
Dupilumab for moderate to severe atopic dermatitis
JAK inhibitors specialist managed due to safety monitoring
Secondary infection management
Bacterial infection pathways
Impetigo limited
Mupirocin topical 2 percent 2 to 3 times daily for 5 days
Reassess if no improvement 48 to 72 hours
Cellulitis or systemic symptoms
Oral antibiotics per local protocol dependent
MRSA risk guided coverage
Culture indications
Purulence
Recurrent infection
Eczema herpeticum pathway
HSV related escalation
Start antivirals if concern
Acyclovir 400 mg PO 5 times daily for 7 to 10 days
Severe disease or immunocompromised consider IV therapy and admission
Ophthalmology consultation triggers
Periorbital lesions
Eye pain
Vision change
Reassessment loop
Reassessment timing
ED reassessment in 30 to 60 minutes if systemic symptoms or anaphylaxis treatment
Outpatient reassessment in 48 to 72 hours if infection concern
Earlier return if rapid progression
Disposition
ICU and resuscitation level care
ICU criteria
Anaphylaxis requiring repeated epinephrine
Hypotension requiring vasopressors
Suspected SJS or TEN with systemic instability
Inpatient admission
Admission indications
Eczema herpeticum with systemic symptoms
Facial cellulitis with systemic symptoms
Failure of outpatient therapy with worsening infection
Inability to maintain hydration or oral intake
Observation pathway
Observation criteria
Moderate infection with need for IV antibiotics
Anaphylaxis observation after stabilization per local protocol dependent
Discharge criteria
Discharge when
No airway or hemodynamic compromise
No mucosal involvement concerning for SJS or TEN
Pain controlled
Clear topical regimen and trigger avoidance plan
Follow up arranged
Follow up timing
Follow up plan
Primary care in 2 to 7 days
Dermatology in 2 to 6 weeks for recurrent or severe disease
Allergy referral for suspected allergic contact dermatitis with recurrent flares
Discharge Instructions
Copy discharge instructions
Skin inflammation flare likely from eczema or contact dermatitis
Stop the suspected trigger product and avoid re exposure
Use a fragrance free thick moisturizer at least twice daily and after bathing
Use the prescribed topical anti inflammatory medication as directed and stop after the planned course
Avoid hot showers and avoid scratching
Return to the ER now for trouble breathing, swelling of lips or tongue, fainting, severe weakness, rapidly spreading painful rash, fever with worsening redness, eye pain or vision changes, mouth sores, or blistering skin
Follow up with your clinician within the recommended time frame or sooner if not improving in 48 to 72 hours
References
Guidelines and high quality sources
Core references
American Academy of Dermatology guidelines of care for the management of atopic dermatitis 2023
American Academy of Dermatology guidelines of care for topical therapy and moisturization in atopic dermatitis 2014
European Society of Contact Dermatitis guideline for diagnostic patch testing 2015
AAAAI practice parameter update for anaphylaxis 2023
IDSA practice guidelines for skin and soft tissue infections 2014
Project instructions file
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.