Hospital skin findings offer key medical insights

Hospitalists should check a patient’s skin before reviewing medical records, a dermatologist advised at Converge 2026. Skin findings often provide faster diagnoses than lab results or imaging, and early detection can alter outcomes for serious rashes.

The skin tells you what is wrong before the chart does

Steven Chen, MD, MPH, MS-HPEd, began his session with a key principle: dermatologists prioritize physical exams over history. He presented five cases demonstrating how skin eruptions appear in hospitalized patients, highlighting what admitting teams should do before requesting a consult.

Each case featured a distinct visual pattern. Chen encouraged hospitalists to recognize these signs to enable rapid action, even without immediate dermatology support.

Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: a race against time

A 69-year-old man with follicular lymphoma developed fevers, muscle pain, and a dusky rash two weeks after starting trimethoprim-sulfamethoxazole for Pneumocystis pneumonia prevention. His condition included atypical target-like lesions, mucosal damage, and a positive Nikolsky sign—where skin detaches under slight pressure. By the third hospital day, the rash covered over 10% of his body, shifting the diagnosis from Stevens-Johnson Syndrome to Toxic Epidermal Necrolysis.

Chen explained the difference between classic target lesions—raised with three distinct rings—and the flat, irregular marks seen in SJS/TEN. The latter indicates a far more severe prognosis. Treatment starts with discontinuing the triggering medication, typically an antibiotic, antiepileptic, or NSAID administered four to 21 days prior. Care includes wound management, considering burn unit transfer, and early consultations with ophthalmology and urology. Debridement is not recommended, and antibiotics should only be used for confirmed infections.

The Severity-of-Illness Score for Toxic Epidermal Necrolysis (SCORTEN) remains the standard for predicting outcomes, though a 2018 U.S. study found actual survival rates often exceed its estimates. Mortality increases significantly once the rash spreads beyond 40% of the body. A 2022 review suggested etanercept may lower disease-related deaths, while 2024 research in Nature identified JAK1 as a potential target, paving the way for ruxolitinib and other JAK inhibitors alongside IVIG and steroids.

Drug Reaction with Eosinophilia and Systemic Symptoms: the slow burn

A 55-year-old man developed a widespread red rash, facial swelling, muscle pain, and joint stiffness five weeks after starting nafcillin for Staphylococcus aureus bacteremia. Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) usually appears two to six weeks after first exposure to the responsible medication—commonly antiepileptics, antibiotics, or antivirals. The condition carries a 10% mortality rate, primarily due to liver failure.

Diagnosis relies on clinical assessment, supported by the RegiSCAR scoring system. A biopsy offers limited help, and neither rash nor raised eosinophils are required for confirmation. Evaluation should include blood counts, liver and kidney function tests, with attention to atypical lymphocytes, swollen lymph nodes, and enlarged organs. Steroids are the primary treatment, often administered intravenously for bowel swelling, followed by a gradual taper. Cyclosporine shows the strongest evidence as a second-line option.

Viral reactivation—particularly of human herpesvirus-6, Epstein-Barr virus, and cytomegalovirus—plays a growing role in DRESS. Patients should have thyroid function monitored two to three months later, as autoimmune thyroiditis is a known complication. Chen’s main lesson: mapping a patient’s drug timeline almost always identifies the cause.

Retiform purpura: the emergency hiding in plain sight

A 44-year-old man arrived at the emergency department with flu-like symptoms a day after a dog bite. During a CT scan, he developed retiform purpura—dark, angular patches with jagged edges. This pattern indicates microvascular blockage, essentially visible disseminated intravascular coagulation. It requires immediate attention.

The possible causes include sepsis from encapsulated bacteria (especially in patients without a spleen), tick-borne illnesses, catastrophic antiphospholipid syndrome, and protein C or S deficiency. Clinicians should ask about splenectomy, vaccination history, animal exposure, and travel. In this case, the patient tested positive for Capnocytophaga canimorsus and died within 72 hours.

Chen emphasized that recognizing retiform purpura early enough to escalate antibiotics, resuscitation, and intensive care is the most practical skill hospitalists can develop for these situations.

Pyoderma gangrenosum: when surgery makes it worse

A 72-year-old woman developed painful, expanding ulcers with undermined edges at her surgical site after a laparoscopic cholecystectomy converted to an open procedure. The diagnosis was pyoderma gangrenosum (PG), a neutrophilic skin disorder that worsens with trauma, including surgical debridement.

Preventing the surgical team from debriding is sometimes the most critical advice a dermatology consult can offer. Diagnosis is clinical and requires ruling out infection through biopsy and cultures. Treatment involves immunosuppression, typically high-dose prednisone, often combined with antibiotics until cultures confirm no infection. Patients with known PG facing future surgery may benefit from perioperative steroids or cyclosporine.

Cutaneous small vessel vasculitis: the common and the complex

Palpable purpura on the lower legs is the hallmark of cutaneous small vessel vasculitis (CSVV), often triggered by medication or infection. It describes a pattern rather than a specific diagnosis—IgA vasculitis, leukocytoclastic vasculitis, and Henoch-Schönlein purpura all fall under this category.

Direct immunofluorescence for IgA deposition becomes less reliable after 48 hours, so timing matters if a biopsy is performed. Most cases resolve with removal of the trigger and topical steroids; systemic treatment is reserved for ulceration. When systemic vasculitis is suspected, additional tests—including ANCA, cryoglobulins, rheumatoid factor, ANA, and complement levels—should be ordered.

Chen’s final advice: not every vasculitis case requires extensive testing if the trigger is clear. But when uncertainty exists, dermatology should be consulted early—before the rash progresses.

Latency periods provide clues. Simple drug rashes appear in one to two weeks, SJS/TEN in four to 21 days, DRESS in two to six weeks, and hives within hours. Retiform purpura signals vasculopathy or vasculitis unless proven otherwise. Early recognition of neutrophilic skin disorders can preserve tissue and save lives.

The session concluded with a reminder: the skin functions as more than an organ. It serves as a diagnostic tool, and hospitalists who learn to interpret it can act faster than any medical record allows. For those looking to refine their approach, lessons on the fly can offer additional strategies.