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be generated by the app. The device is designed to work on all variants of smart phones and with other mobile services such as WhatsApp and e- mail.5

The Indian Council of Medical Research (ICMR) in collaboration with the All India Institute of Medical Sciences (Delhi) has launched a pilot project ‘ Mission DELHI’ (Delhi Emergency Life Heart- Attack Initiative) in a range of three km around its perimetry where one will be able to call for motorbike borne emergency medical assistance in the eventuality of heart attack or chest pain. Under this project, a pair of motorcycle borne trained paramedic nurses would be the first responders for treat ing patients with cardiac arrest / chest pain. They will record the ECG and have a virtual connect to the cardiologist at AIIMS; then deliver appropriate medical therapy including thrombolysis before arrival of ambulance.6 Out of three imaging modalities ECG plays an important role in recognising patients of coronary artery disease and help providing them appropriate guidance, counselling and treatment during telemedicine session. Cardiac imaging is an integral aspect in the diagnosis and monitoring of cardiovascular diseases.7 Besides ECG, X -ray and ultrasound are also important in complementing comprehensive

diagnosis of cardiovascular diseases particularly complications of obesity, diabetes and hypertension. Coincidental detection of asymptomatic renal stones in large number (42%) of our cases merit further research to assess the reasons behind this finding. The use of telemedicine is useful in delivery of effective health care for patients with cardiovascular disease.8

Strengths and Limitations

Telemedicine is an accessible and cost-effective mode of healthcare for rural patients. It provides access to consult specialists . The images of ultrasound and chest x-ray are not always clear due to poor resolution of filmConclusion

ECG, chest X-ray and ultrasound images can be transmitted and used as a convenient laboratory tool in te lemedicine for the diagnosis of cardiovascular diseases, particularly those who have fatty liver, diabetes mellitus, hypertension and/or CAD. In a developing country like India where medical advancements are not yet available in every nook and corner of the country, telemedicine can be a useful tool as it overcomes the distance barrier. We found that in rural

hinterland diabetes is more prevalent than hypertension. That day is not far when Echo and other diagnostic images like CT and cardiac MRI would be available at community health centres at villages and such images would be transmitted to apex centres through telemedicine.Acknowledgement

Coordinat ion provided by Mrs Indritta Singh D’mello, Director of Hospital Guide Foundation (HGF) is gratefully acknowledged.

References 1. Dwivedi S, Yadava OP, Roy K. Telemedicine: A valuable,

epidemiological, & therapeutic tool for cardiovascular diseases in rural area. MGM J Med Sci 2019; 10:1–4.

2. World Health Organization. Global Atlas on Cardiovascular Disease Prevention and Control.Geneva;2011

3. Prasad KP, Prasad SG. Te lemedic ine and Tele - echocardiography in India. Journal of the Indian Academy of Echocardiography and Cardiovascular Imaging 2017; 1:109-118.

4. Sharma S. Telemedicine: an era yet to flourish in India; Ann Natl Acad Med Sci (India) 2018; 54:114-19.

5. Mohan A. News from here there, Handheld ECG. Natl Med J India 2018; 31:382-384.

6. Syed Adil Shamin Andrabi. Mission Delhi Pilot Project. Indian Council of Medical Research (ICMR) 2019; 1-12.

7. Stokes MB, Roberts-Thompsons R. The role of cardiac imaging in clinical practice. Aust Prescr 2017; 40:151-155.

8. Brunetti ND, Scalvini S, et al. Telemedicine for cardiovascular disease continuum: a position paper from Italian society of cardiology working group on Telecardiology and informatics. Int J Cardiol 2015; 184:452–458.

Dermatological Disorders in the Intensive Care Unit: A Descriptive Study at a Tertiary Care CentreAnkita Srivastava1*, AD Mathur2, Sakshi Agarwal3

1Assistant Professor, Department of Dermatology, AIIMS, Nagpur, Maharashtra; 2Professor, Department of General Medicine, JNUIMSRC, Jaipur, Rajasthan; 3Senior Resident, Department of Dermatology, Swami Dayanand Hospital, New Delhi *Corresponding AuthorReceived: 25.12.2019; Accepted: 06.08.2020

AbstractBackground: Dermatological disorders are common in patients being treated in intensive care units (ICU). However, they are often neglected in context of a critically ill patient. Very few studies focusing on these dermatoses have been undertaken.

Objectives: To determine the prevalence and spectrum of dermatological disorders in patients being treated in medical ICU of a tertiary care centre.

Methods: This was a descriptive study conducted over a period of one year. All the patients admitted in the medical ICU were examined for the presence of any preexisting or newly developed dermatological disorder. Dermatological disorders were initially classified into infective and non-infective disorders. Patients with dermatological findings were classified into two groups: those who survived and those who died; which were compared with each other with respect to age and sex distribution, length of ICU stay and dermatological findings.

Journal of The Association of Physicians of India ■ Vol. 69 ■ November 2021 37

Results: Out of 776 cases admitted in ICU during the study period, dermatological disorders were observed in 164 (21.13%) cases. Life-threatening dermatological disorders were seen in 3.05% cases. Twenty nine (17.68%) patients with dermatological findings died. Amongst these cases, infectious dermatological disorders were significantly less common; while no significant difference was noticed in context of reactive dermatological disorders.

Conclusion: Dermatological disorders in ICU are common and have a wide spectrum. They often need treatment and may be indicative of underlying potentially fatal systemic illness. Besides, a subset of cutaneous lesions may develop in response to various medical interventions, immunosuppression and immobility. Knowledge of such dermatoses is thus, essential, both for the intensivist and dermatologist.

Introduction

Dermatological disorders in the intensive care unit (ICU) are often

considered trivial. This is because most of the dermatological diseases are not life-threatening. However, there are Table 1: Age and sex distribution of cases

with dermatological disorders

Age (in years) M F Total Percentage Upto 20 12 6 18 10.96%21 – 40 20 16 36 21.95%41 – 60 33 17 50 30.49%>60 42 18 60 36.56%Total 107 57 164 100.00%

Fig. 1: Various dermatological disorders noticed in the medical ICU (a) Rhinocerebral mucormycosis; (b) Herpes zoster; (c) Oral candidiasis; (d) Palpable purpura as a part of systemic vasculitis; (e) Purpura fulminans as a manifestation of disseminated intravascular coagulation (DIC); (f) Pressure sore; (g) Miliaria crystallina; (h) Xerosis; (i) Gangrene

Table 2: Infective dermatological disorders noted in the ICU

Bacterial Total Preexisting Newly developed

Folliculitis 2 2 0Furuncle 2 2 0Cellulitis 1 1 0Syphilis 1 1 0Leprosy 1 1 0Total 7 7 0Viral Herpes simplex 4 0 4Herpes zoster 4 3 1Molluscum contagiosum

1 1 0

Viral exanthem (Dengue)

1 0 1

HIV 1 1 0Total 11 5 6Fungal Dermatophytosis 23 23 0Candidiasis 5 1 4Pityriasis versicolor

5 5 0

Rhinocerebral mucormycosis

1 1 0

Total 34 30 4Parasitic Scabies 3 3 0Total 3 3 0Total infective dermatological disorders

55 45 10

certain dermatological diseases, which are severe enough to be treated in an ICU. Fortunately, the prevalence of such disorders is quite low, with a reported frequency of 0.42–0.47%.1,2 On the other hand, several dermatological findings are noted in critically ill patients being treated in ICUs; which may or may not be related to the primary illness. Sometimes, the cutaneous lesions might be an indicator of underlying systemic disease. Although most of the dermatological disorders are not life-threatening, they may impair patients’ quality of life. They can also occur as

an adverse effect of medical intensive care due to the use of several drugs, interventions or inadequate skin care.3

Dermatologists often find it difficult to diagnose the cutaneous lesions in such patients, partly due to difficulty in history taking and examination.3,4 Furthermore, while treat ing even the most common dermatoses in the ICU, one needs to be cautious about the comorbidities and possible drug interactions.

Very few studies2-7 across the globe have been conducted to investigate various dermatological disorders in patients requiring intensive care. Also, none of the standard dermatology textbooks have a chapter dedicated to these ‘ICU dermatoses.’ Therefore, we conducted this observational study to determine the prevalence and spectrum of dermatological disorders in patients being treated in medical intensive care unit at a tertiary care centre.

Material and Methods

This was a descriptive study, carried out at a tertiary care centre over a period of one year. The study was approved by the institutional ethics

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committee. All the patients admitted in the medical ICU as per the society of cr i t ica l care medic ine (SCCM) guidelines8 were screened within 24 hours of admission for the presence of any dermatological disorder and were followed up daily till discharge or death. The relevant details including age, sex, preexisting dermatological disorders and systemic illness were n o t e d . D e r m a t o l o g i c a l f i n d i n g s were recorded with respect to onset, duration, morphology, distribution a n d p r o g r e s s i o n . T h e d i a g n o s i s was made clinically with relevant laboratory investigations as and when needed. Appropriate treatment for the dermatological disorder was instituted in collaboration with the treating physic ian and/or intensivist . The patients with dermatological findings were classified into two groups: those who survived and those who died.

These two groups were compared with each other with respect to age and sex distribution, length of ICU stay and dermatological findings.

Statistical analysis: The prevalence of dermatological disorders in the ICU was calculated as the proportion o f p a t i e n t s w h o h a d c u t a n e o u s manifestations either at the time of admission or developed later during the course of treatment in the ICU.

D i s c r e t e c a t e g o r i c a l d a t a i s represented as n (%); continuous data as mean ± SD and range or median and interquartile range, as appropriate. For a comparison of the variables, the χ2 (chi square) test was used for categorical variables; and the Mann-Whitney U test was used for continuous variables. Differences between values were considered significant at p < 0.05. Analysis of data was carried out by using Statistical Package for the Social

Sciences software, version 20 (IBM® SPSS Statistics).

Results

A total of 776 patients were admitted in the medical ICU over a period of one year (from January 2018 to December 2018) . Out of these , 164 (21 .13%) patients had dermatological disorders. These patients included 107 (65.24%) males and 57 (34.76%) females. Age ranged from 13 years to 85 years with average age of 49.96 ± 19.07 years. Age and sex distribution is shown in Table 1.

The average length of stay in ICU was 7.69 ± 6.38 days, ranging from 1 day

Table 4: Classification of dermatological disorders in the ICU and associated mortality

Type of dermatological disorder

Total no. of cases noted

No. of patients who died

Infective dermatological disorders

55 3

Previous dermatological disorders

62 10

Life-threatening dermatologic disorders

5 2

Systemic dermatological disorders

36 12

Reactive dermatological disorders

36 7

Table 5: Comparison of patients (with dermatological disorders) who survived and those who died

Parameter Patients with dermatological disorders who survived

(n = 135)

Patients with dermatological disorders who died

(n = 29)

p value

Mean age (years) 49.16 ± 19.04 53.69 ± 18.79 0.322Sex (males, percentage) 86 (63.7%) 21 (72.41%) 0.371Length of ICU stay (days) 7.55 ± 5.73 8.31 ± 8.78 0.555Infective dermatoses 50 (37.04%) 3 (10.34%) 0.005Newly developed lesions 47 (34.81%) 12 (41.38%) 0.503Systemic dermatological disorders 24 (17.78%) 12 (41.38%) 0.005Reactive dermatological disorders 29 (21.48%) 7 (24.14%) 0.753

Table 3: Various non-infective dermatological disorders noticed in the ICU

Dermatological disorder Total cases

Preexisting Newly developed

Purpura 21 10 11• Purpura fulminans 2 1 1• Senile purpura 6 6 0

• Traumatic 11 2 9• Due to thrombocytopenia 2 1 1Xerosis 19 13 6Dermatitis 12 12 0Thrombophlebitis 11 0 11Post oedema exfoliation 7 0 7Pressure ulcer 6 3 3Psoriasis/sebopsoriasis 6 6 0Angular cheilitis 5 1 4Miliaria 5 0 5Traumatic erosions on lips 4 0 4Acne vulgaris/acneiform eruption 4 4 0Pigmentary disorders• Vitiligo 4 4 0• Melasma 3 3 0• Idiopathic guttate hypomelanosis 3 3 0Connective tissue disorders• Systemic lupus erythematosus 3 3 0• Systemic sclerosis 2 2 0Vasculitis 2 2 0

Dermatological disorder Total cases

Preexisting Newly developed

Immunobullous disorders• Pemphigus vulgaris 3 3 0• Dermatitis herpetiformis 1 1 0Gangrene 2 2 0Coma blisters 2 0 2Skin tags 4 4 0Seb keratosis 2 2 0Angiokeratoma 1 1 0Anagen effluvium 1 1 0Erythroderma 1 1 0Toxic epidermal necrolysis 1 1 0Perforating disorder 1 1 0Cutaneous infarcts 1 1 0Dyssebacia 1 1 0Urticaria 1 0 1Traumatic abrasion 1 1 0Senile comedones 1 1 0Xanthelesma palpebrarum 1 1 0Total non-infective dermatological disorders*

142 88 54

*Some patients had more than one dermatological disorder

Journal of The Association of Physicians of India ■ Vol. 69 ■ November 2021 39

to 43 days. Out of these 164 patients, 103 (62.8%) had preexisting dermatological disorders, while 44 (26.83%) cases developed new cutaneous lesions while being treated in the ICU. The remaining 17 (10.37%) patients had both – preexisting dermatoses, and they also developed new lesions during ICU stay. The average duration of ICU stay before onset of new cutaneous lesions was, 6.08 ± 4.69 days, ranging from 1 day to 22 days. A total of 40 (24.39%) cases had more than one dermatological condition.

S p e c t r u m o f d e r m a t o l o g i c a l disorders in the ICU: A variety of dermatological disorders were noted in the study (Figure 1). We broadly classified these disorders into infective and non-infective. Final diagnosis could not be established in six (3.66%) cases due to death or leaving against medical advice. Five (3.05%) cases were admitted in the ICU for primary d e r m a t o l o g i c a l d i s o r d e r s . T h e s e included 3 cases of pemphigus vulgaris and one each of erythroderma and toxic epidermal necrolysis (TEN). In addition, two cases of herpes zoster were shifted from dermatology ward to ICU, due to development of systemic complications.

Infectious dermatological diseases were seen in 55 (33.54%) cases, further classified into bacterial, viral, fungal and parasit ic . Of these cutaneous in fec t ions , ma jor i ty (45 , 81 .81%) were preexisting, only 18.18% cases developed these manifestations after admission in ICU. Overall , fungal skin infections were the most common followed by viral infections. The details are shown in Table 2.

A t o t a l o f 1 4 2 n o n - i n f e c t i o u s dermatoses were noticed in 115 (70.12%) cases. Few cases had both infectious and non-infectious manifestations. The details are enumerated in Table 3. Most commonly encountered non-infect ive cutaneous manifestat ion was purpura followed by xerosis. We further classified these non-infective dermatoses according to classification proposed by Badia et al3 (Table 4).

Treatment was init iated for al l cases with infectious dermatoses, and 85 (59.86%) cases of non-infective dermatoses . The remaining cases were either part of systemic disease (eg. connective tissue disorders) or were benign dermatoses for which no

immediate intervention was needed (eg skin tags, melasma). Out of these treated cases, however, we needed to modify the standard treatment in 31 (22.14%) cases, taking care of comorbidities and concurrent medications.

Out of these 164 patients, 29 (17.68%) died. It included 21 (72.41%) males and 8 (27.59%) females. The average age was 53.69 ± 18.79 years. The median ICU stay in these patients was 5 days (mean ICU stay: 8.31 ± 8.78 days). Only three (10.34%) cases suffered from infectious dermatoses, while 23 cases (79.31%) had non-infectious dermatoses. Final diagnosis could not be established in remaining three patients. In nine (31.03%) of these cases, cutaneous lesions were either part of fatal systemic illness, or contributed directly to death. These included two cases of systemic sc lerosis and purpura fulminans, and one case each of pemphigus vulgaris, TEN, SLE, vasculitis and rh inocerebra l mucormycos i s . No statistically significant difference was found between age and sex-distribution of patients who died and those who survived (Table 5).

Discussion

Most of the dermatological disorders are not life-threatening. Hence, they are often ignored in a critically ill patient being treated in ICU. But, sometimes, the dermatological findings may aid the physician in establishing the diagnosis. That’s why skin is often regarded as a window to systemic disease.9 Also, the coexistent dermatological disorders may impair patient’s quality of life and need definite treatment also. In ICUs, as the patients are not able to take care of themselves, sometimes, cutaneous lesions may develop due to lack of adequate skin care and also as a result of various therapeutic interventions.3 Therefore, the medical team in the ICU must be aware of var ious dermatological disorders prevalent in ICU and pay adequate attention to them, in order to provide best possible care to the patient.

A d e q u a t e m e d i c a l l i t e r a t u r e focusing on dermatological disorders in the ICU does not exist. However, based on available data, the prevalence of dermatological disorders in the ICU varies from 2.3% to 42.2%.2-7,10-12 Many of these studies2,4,6,11,12 have taken up only those patients for whom a dermatology

consultation was requested, therefore, resulting in a false low prevalence. In the present study, the prevalence of dermatological disorders in the ICU was 21.13%. This is relatively higher, possibly because we screened all the patients in ICU and recorded all the dermatological findings whether they were associated with primary reason for ICU admission or not.

Owing to wide variety of dermatoses prevalent in the ICU, establishing a uniform system of classification is difficult. We initially classified the cutaneous findings into infectious and non-infectious dermatoses and then classified the non-infectious cases further as per classification proposed by Badia et al.3

It was noticed that non-infective d e r m a t o s e s we r e m o r e c o m m o n than infective dermatoses. The most common of these was purpura followed by xerosis and/or asteatotic dermatitis. Though both of these manifestations may not require immediate additional therapy, but they can point towards various causative factors. Both xerosis and purpura can occur simply as a part of senile skin changes.13,14 But at the same time, these can also occur as a result of internal disease, drugs and inadequate skin care and/or frequent cutaneous trauma. Sometimes, these can point towards fatal systemic illness (eg purpura fulminans) hence it is advisable to carefully analyse these manifestations.

As per classification proposed by Badia et al, preexisting non-infective dermatoses were seen in 62 cases, much higher than previous studies. This is because in previous studies many cutaneous findings such as skin tags, acne, melasma, pressure sores etc were not included; as they were not considered relevant in context of patient’s condition.3

Life-threatening dermatological disorders were seen in five (3.05%) cases, a figure close to available literature. This group basically incorporates disorders that may result in acute skin failure, such as immunobullous disorders, TEN and erythroderma.15,16 Though, the prevalence of such disorders is low, but these are associated with high mortality due to complications including sepsis and multiorgan failure. These patients, therefore, require specialized care under collaboration of dermatologist

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and intensivist. Some researchers have also recommended the dermatology ICUs or specialized units dedicated for the treatment of these disorders.17,18

A total of 36 reactive dermatological disorders were recorded in the study. This category included disorders which developed after admission in ICU and are related to factors like inadvertent mucocutaneous trauma during therapeutic interventions, prolonged immobility, poor nutrition, immunosuppression etc . Common d i s o r d e r s i n t h i s g r o u p i n c l u d e thrombophlebitis, angular cheilitis, t raumatic erosions on l ips (while intubation) and purpura (at sites of injection/cannulation).

Systemic dermatological disorders form a large group amongst dermatoses p r e va l e n t i n I C U s a n d i n c l u d e d h e t e r o g e n o u s e n t i t i e s i n c l u d i n g connective tissue disorders, vasculitis, purpura, and gangrene. The spectrum of skin manifestations of systemic disease is wide and these can be specific and nonspecific.9 This group is important to recognize because these manifestations often give clue towards the diagnosis and the disease can turn out to be fatal. In terms of mortality, this group accounted for 41.37% cases of deaths.

I n o u r s t u d y , i n f e c t i o u s dermatological disorders were observed in 33.54% cases, out of which fungal infections were most common followed by viral infections. This is consistent with previous studies.

We also tried to classify the cutaneous manifestations into pre-existing and newly developed lesions. It helped in recognizing a subset of dermatological findings that often occur either as a result of various interventions, inadequate nutrition, poor skin care, immobility and immunosuppression. I t a lso inc luded certa in infect ive conditions such as herpes simplex react ivat ion and candidiasis . The drawback of this system is that a particular dermatological finding could be pre-existing in some patients and can develop later in others.

In the present study, we compared the pat ients who died and those w h o s u r v i v e d . N o s t a t i s t i c a l l y s igni f i cant d i f ference was found between age and sex-distribution of both groups. Amongst patients who died, the proportion of patients with

infectious dermatological disorders was significantly lower than those with non-infectious dermatological d i s o r d e r s . O n l y t h r e e c a s e s h a d cutaneous infections– one each with rhinocerebral mucormycosis, herpes zoster and dermatophytosis. These patients had comorbidities such as diabetes mellitus, hypertension and chronic renal failure which contributed to death. No significant difference, however, was noticed in context of react ive dermatological disorders amongst both the groups. Available literature does not give adequate data about dermatoses in patients who died; hence it difficult to compare these results . We suggest further studies focusing on this aspect of ‘ICU dermatoses’ which might be useful in prognosticating the patients.

Treatment for the dermatolgical disorder was initiated in all cases of infective dermatoses and approximately 60% cases of non-infective dermatoses. Certain cases, such as purpura due to thrombocytopenia, malar rash of SLE needed no additional treatment apart from treatment of primary illness, while definitive treatment of conditions such as skin tags, melasma, xanthelesma etc was deferred till patient improved, considering the benign nature of these diseases. However we would like to underscore that in several patients, the usual dermatological therapy needed to be modified. Some examples include reduced dose of antivirals in patients with chronic kidney disease, choosing appropriate ant i fungal , reduced need of antihistamines and delaying immunosuppressants t i l l systemic infection improves. In the era with gradual shrinking of inpatient dermatology services,19 it is essential for dermatologists to be aware of these considerations while treating a patient having multiple health problems.

It may be quite difficult for the intensivist to diagnose and/or treat patients with dermatological disorders. While many of the cutaneous lesions are innocuous, some of them can prove to be fatal . There is a lso a subset of cutaneous lesions which d e ve l o p i n r e s p o n s e t o m e d i c a l interventions, immunosuppression and immobility. Hence, it is essential that the intensivists timely examine and recognize such disorders with dermatology consultation whenever required. Jack et al20 provide handy

guidelines, which could be adopted in the ICUs. Collaboration between d e r m a t o l o g i s t a n d i n t e n s i v i s t i s helpful in identifying these cutaneous manifestations to provide the best possible care to the patient.

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PS. Dermatological conditions in intensive care: a secondary analysis of the Intensive Care National Audit and Research Centre (ICNARC) case mix programme database. Crit Care 2008; 12:S1.

2. Dunnill MG, Handfield-Jones SE, Treacher D, McGibbon DH. Dermatology in the intensive care unit. Br J Dermatol 1995; 132:226–35.

3. Badia M, Servia L, Casanova JM,   Montserrat N, Vilanova J, Vicario E, et al. Classification of dermatological disorders in critical care patients: a prospective observational study. J Crit Care 2013; 28:220.e1-8.

4. Emre S, Emre C, Akoglu G, Demirseren DD, Metin A. Evaluation of dermatological consultations of patients treated in intensive care unit. Dermatology 2013; 226:75-80.

5. Agrawal P, Peter JV, George R. Dermatological manifestations and relationship to outcomes of patients admitted to a medical intensive care unit: a study from a tertiary care hospital in India. Postgrad Med J 2013; 89:501-7.

6. Fischer M, Soukup J, Wohlrab J, Radke J, Marsch W: Key dermatological symptoms in the intensive care unit. Int J Dermatol 2004; 43:780–782.

7. Badia M, Trujillano J, Gascó E, Casanova JM, Alvarez M, León M. Skin lesions in the ICU. Intensive Care Med 1999; 25:1271–76.

8. Nates JL, Nunnally M, Kleinpell R, Blosser S, Goldner J, Birriel B, et al. ICU Admission, Discharge, and Triage Guidelines: A Framework to Enhance Clinical Operations, Development of Institutional Policies, and Further Research. Crit Care Med 2016; 44:1553-602.

9. Lee A. Skin manifestations of systemic disease. Aust Fam Physician 2009; 38:498-505.

10. Fisher M, William T, Wohlrab J. Skin diseases in intensive care medicine. J Dtsch Dermatol Ges 2009; 7:108-15.

11. Wollina U, Nowak A. Dermatology in the intensive care unit. Our Dermatol Online 2012; 3:298-303.

12. Pektas SD, Demir AK. Prospective analysis of skin findings in medical critically ill patients in intensive care units. Int J Clin Exp Med 2017; 10:14770-7.

13. Patange SV, Fernandez RJ. A study of geriatric dermatoses. Indian J Dermatol Venereol Leprol 1995; 61:206-8.

14. Reszke R, Pełka D, Walasek A, Machaj Z, Reich A. Skin disorders in elderly subjects. Int J Dermatol 2015; 54:e332-8.

15. Inamadar AC, Palit A. Acute skin failure: Concept, causes, consequences and care. Indian J Dermatol Venereol Leprol 2005; 71:379–85.

16. Vaishampayan SS, Sharma YK, Das AL, Verma R. Emergencies in dermatology: Acute skin failure. Med J Armed Forces India 2006; 62:56–9.

17. Hassan I, Rather PA. Emergency dermatology and need of dermatological intensive care unit (DICU). J Pakistan Assoc Derma 2013; 23:71–82.

18. Mitra D, Chopra A, Saraswat N, Agarwal R, Kumar S. An observational study to describe the clinical pattern of dermatological emergencies from emergency department and intensive care unit: our experience from a tertiary care hospital in northern India. Indian Dermatol Online J 2019; 10:144-148.

19. Strowd LC. Inpatient dermatology: a paradigm shift in the management of skin disease in the hospital. Br J Dermatol 2019; 180:966-967.

20. Jack AR, Spence AA, Nichols BJ, Peng DH: A simple algorithm for evaluating dermatologic disease in critically ill patients: a study based on retrospective review of medical intensive care unit consults. J Am Acad Dermatol 2009; 61:728–730.