Dermatologic Conditions in The Critically Ill
May 11, 2015
Dermatologic Conditions in The Critically Ill
Critical Functions of The Skin
Barrier function: water and electrolytes
Mechanical protection
Perform wound repair
Immune function
Maintain body temperature
Loss of Barrier Function
Massive fluid and electrolyte loss
Profound calorie loss
Invasion of microorganism
hypothermia
General Principles of Treatment
Eliminate suspicious precipitating factors
Aggressive volume status monitoring
Nutritional support
Culture of affected skin
Bed rest of fluidized bed
Mild sedation and antihistamines
Meticulous mucous membrane and eye care
Frequent debridement
Life-threatening Dermatologic Conditions
Toxic epidermal necrolysis (TEN)
Pemphigus vulgaris
Pustular psoriasis
Exfoliative dermatitis
Erythema multiforme
Toxic Epidermal Necrolysis
Widespread erythema and epidermal sloughing
Many etiology factors (drug reactions: sulfonamides, butazones, hydantoins)
Immune mechanism
High morbidity and mortality
Toxic Epidermal Necrolysis- Clinical Manifestations -
Early TEN: indistinguishable from EM, drug reaction, SSSS, chemical burnProdromal symptoms: skin tenderness, conjunctiva burning, fever, malaise, arthralgiaMorbilliform rash begins on face and limbsFollowed by vesicles, bullae, rupture of bullae, denuded skin up to 50% BSA or moreNikolsky’s sign (+)Severe mucous membrane involvement
Toxic Epidermal Necrolysis- Complications -
Hypovolemia
Septic shock
Pulmonary edema, renal failure
GI bleeding
Tracheitis, bronchopneumonia
Acute tubular necrosis, membranous glomerulitis
Toxic Epidermal Necrolysis- Treatment -
Adequate supportive care
High-dose corticosteroid (prednisolone 250mg/day): controversial
Topical antimicrobials
Tissue grafts
Burn ICU
Mortality rate: 25-50%
Heal with scarring: common
Pemphigus Vulgaris
Autoimmune disease
4th to 5th decades
Flaccid bullae
Nikolsky’s sign (+)
Diagnosis: skin biopsy with DIF, IIF
Serum IgG titer
Pemphigus Vulgaris- Treatment -
Topical wet dressing with normal saline
Prednisolone 240mg/day
Adjuvant therapy: methotrexate, azathioprine, cyclophosphamide, gold
Pustular Psoriasis
Generalized erythroderma and pustules
Provocative factors: infection, pregnancy, sunlight, drugs (salicylate, iodide, lithium, phenylbutazone), sudden withdrawal of systemic corticosteroids
Pustular Psoriasis- Clinical Manifestations -
Waves of pustules and corneal exfoliation
Exacerbation of polyarthritis
Leukemoid reaction, hypoalbuminemia
Pustular Psoriasis- Treatment -
Topical low-potency steroid
bland emollient
PUVA
Etretinate
methotrexate
Exfoliative Dermatitis
Generalized erythema and scaling
Associated with preexisting dermatoses, malignancy, drugs or idiopathic
Tx: underlying disease
Erythema Multiforme
Target lesions
EM minor vs. EM major (Stevens-Johnson syndrome)
A delayed hypersensitivity reaction
Many etiologic factors: herpes, mycoplasma, drugs….etc.
Erythema Multiforme
Complications 10% visual impairment Evolution to TEN Mucosal damage Pneumonia: 18% of
death
Treatment: systemic steroid?
Dermatologic Complications of Critically Ill Patients
Drug reaction
Contact dermatitis
Decubitus ulcer
Steroid acne
Asteatotic eczema
Miliaria
Cutaneous dopamine infusion complication
Drug Reaction
Mechanism unknownIncidence 3/10002/3 caused by sulfonamides, penicillins, and blood productsTypical rashes: urticaria, angioedema, and morbilliform rash
Latency: within 36 hours to a few weeks
Treatment: discontinue responsible drugs
Contact Dermatitis
Irritant dermatitisstrong alkalis, acids, frequent washallergic contact dermatitisPara-aminobenzoid acid derivative local anesthetics (Procaine), topical antibiotics (neomycin, nitrofurazone, penicillin), topical antihistamine, balsam of Peru (tincture of benzoin, rubber gloves), acrylic monomer and nickle in orthopedic use
Decubitus Ulcer
Pelvic area, legs
Rish factors: pressure, fracture, fecal incontinence, urinary catheter, weight loss, hypoalbuminemia
Manage according to the classification
Steroid Acne
Uniform, small papules and pustules on neck, chest and back
NOT a contraindication to continued use of oral steroid
Asteatotic Eczema
In elderly, atopy
Anterolateral aspect of legs
Wet dressing then lubrication with petrolatum or lanolin
Topical steroid ointment or cream
Miliaria
Heat rash
Eccrine duct occlusion
Miliaria crystallina
Miliaria rubra
Tx: skin ventilation, change bed linen
Selected Conditions with Distinctive Cutaneous FindingsAIDSSubacute bacterial endocarditisSepsisPurpuraMalignant infiltrateHerpes simplex and zosterCutaneous necrotizing vasculitisBullous pemphigoid
Disseminated candidiasisSLEOsler-Weber-Rendu syndromePorphyria cutanea tardaCarbon monoxideNecrolytic migratory erythemaErythema chronicum migrans
Subacute Bacterial Endocarditis
Petechia
Splinter hemorrhage
Osler nodes
Janeway lesions
Sepsis
Neisseria gonorrhoeaecrops of tender hemorrhagic papules near joints, <10 lesionsNeisseria meningitidisheadache, nausea, vomiting, fever;hemorrhagic rash, stuporPseudomonas aeruginosahemorrhagic vesicle, ecthyma gangrenosum, gangrenous cellulitis, nodular cellulitis
PurpuraSenile purpuraDrug purpuraampicillin, chlorothiazide, phenylbutazone, sulfonamidesPurpura fulminansgr. A streptococcal infection, scarlet fever, staphylococcal and pneumococcal bacteremia, meningococcemia, varicella
Herpes Simplex and Zoster
Severe complication
esophagitis, pneumonitis, hepatitis, gastroenteritis, encephalitis
Immunocompromise patients
Herpes Simplex and Zoster- Treated with Acyclovir -
Indications
~ Immunocompromised
~ trigeminal or sacral nerve (zoster)
~ dissemination
Dose
oral: 400-800mg 5 times
Iv drip: 5-10mg/kg q8h
Cutaneous Necrotizing Vasculitis
Leukocytoclastic vasculitis
Palpable purpura
Coexisting chronic disease, infection, drugs, idiopathic
Bullous Pemphigoid
Age 50-70y/o
Large, tense bullae, urticarial or erythematous base
Inner thigh, axillae, groin, elbow, lower abdomen, sole, palm
Tx: prednisolone 50-100mg/day
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