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

Quiz 1-4

Quiz 7-8