EMERGENCIES IN EMERGENCIES IN DERMATOLOGYDERMATOLOGY

Acute Skin FailureAcute Skin Failure

ICU in the Skin ICU in the Skin departmentdepartment Prof Rene Touraine first Prof Rene Touraine first

established an ICU in the skin established an ICU in the skin Dept. in 1974Dept. in 1974

Now recognized as a necessity Now recognized as a necessity due to large number of extensive due to large number of extensive skin diseases eventuating into the skin diseases eventuating into the potentially fatal syndrome of potentially fatal syndrome of ‘acute skin failure’‘acute skin failure’

Emergency - DefinedEmergency - Defined

‘‘A risk perceived by a doctor or a A risk perceived by a doctor or a patient to life, limb or the patient to life, limb or the structure / function of an structure / function of an important organ of the body’important organ of the body’

ConsequencesConsequences

Disfiguring dermatoses can Disfiguring dermatoses can generate emergency situationsgenerate emergency situations– Disproportionate and spectral Disproportionate and spectral

psychocutaneous morbiditypsychocutaneous morbidity– Disruption of psychosocial function of Disruption of psychosocial function of

self worth and emotional expressionself worth and emotional expression– Disrupt interconnected anatomy and Disrupt interconnected anatomy and

physiology of skinphysiology of skin

EmergenciesEmergencies

AnaphylacticAnaphylactic ExanthematousExanthematous Acute eczematousAcute eczematous Urticarial / angioedematousUrticarial / angioedematous PurpuricPurpuric Photosensitive reactionsPhotosensitive reactions SJS - TENSJS - TEN

Emergencies in New Emergencies in New bornborn Purpura fulminansPurpura fulminans Lamellar desquamationLamellar desquamation Infantile acute hemorrhagic Infantile acute hemorrhagic

oedemaoedema Sclerema neonatorumSclerema neonatorum Congenital absence of skin and Congenital absence of skin and

metabolic disorders like porphyriasmetabolic disorders like porphyrias

EtiopathogenesisEtiopathogenesis

Failure of skin to perform its Failure of skin to perform its multiple functions can lead tomultiple functions can lead to– Acute failure of heart, lung, kidney Acute failure of heart, lung, kidney

and death consequent to structural and death consequent to structural and functional alterations in various and functional alterations in various components of the skincomponents of the skin

Stratum CorneumStratum Corneum

Destruction of Stratum corneumDestruction of Stratum corneum– Increase in fluid loss by 40 timesIncrease in fluid loss by 40 times

50% of BSA involvement leads to daily 50% of BSA involvement leads to daily fluid loss of up to 4-5 litresfluid loss of up to 4-5 litres

Loss of proteins, Na, K, Cl in the bullous Loss of proteins, Na, K, Cl in the bullous fluid leads to a decreases in intravascular fluid leads to a decreases in intravascular volumevolume

Resultant decrease in urinary output and Resultant decrease in urinary output and increase in blood nitrogen can lead to increase in blood nitrogen can lead to renal failurerenal failure

Altered barrier Altered barrier function function Damaged skin + exudates Damaged skin + exudates

support growth of support growth of microorganismsmicroorganisms– Systemic infections, severe sepsis Systemic infections, severe sepsis

and deathand death Altered immunological functionAltered immunological function

Common dermatoses Common dermatoses leading to acute skin leading to acute skin failurefailure Exfoliative dermatitisExfoliative dermatitis Bullous diseasesBullous diseases Pemphigus vulgarisPemphigus vulgaris Bullous pemphigoidBullous pemphigoid Erythema multiformeErythema multiforme Toxic Epidermal NecrolysisToxic Epidermal Necrolysis

Exfoliative DermatitisExfoliative Dermatitis

Erythema and scaling involving a Erythema and scaling involving a large BSAlarge BSA

Psoriasis – the most common Psoriasis – the most common antecedent illnessantecedent illness

Miscellaneous causes include Miscellaneous causes include ichthyosis, pemphigus, TEN, crusted ichthyosis, pemphigus, TEN, crusted scabies, etcscabies, etc

Intake of drugs like sulphonamides, Intake of drugs like sulphonamides, dapsone, antiepileptics, penicillins, etc dapsone, antiepileptics, penicillins, etc 10 – 15% of the cases10 – 15% of the cases

Bullous DiseaseBullous Disease

Immunobullous diseases like Immunobullous diseases like pemphiguspemphigus

Pemphigoid, etcPemphigoid, etc Hereditary mechanobullous Hereditary mechanobullous

disorders like epidermolysis disorders like epidermolysis bullosa can be life threateningbullosa can be life threatening

Pemphigus VulgarisPemphigus Vulgaris

There are 3 main types of There are 3 main types of pemphigus pemphigus – P. foliaceous (blister in the superficial P. foliaceous (blister in the superficial

granular layersgranular layers– P. vulgaris ( the blisters just above P. vulgaris ( the blisters just above

the basal layer)the basal layer)– Paraneoplastic pemphigus that occurs Paraneoplastic pemphigus that occurs

in association with malignancyin association with malignancy

Lesions in PemphigusLesions in Pemphigus

Flaccid blistersFlaccid blisters ErosionsErosions Nikolsky’s sign is positiveNikolsky’s sign is positive Oral mucosal involvement is Oral mucosal involvement is

universaluniversal

Bullous PemphigoidBullous Pemphigoid

Subepidermal blistering skin disease of Subepidermal blistering skin disease of the elderlythe elderly

Characterized by large, tense, bullae Characterized by large, tense, bullae arising on normal or erythematous skinarising on normal or erythematous skin

Eroded skin tends to reepitheliseEroded skin tends to reepithelise Drugs like penicillin, furesemide, Drugs like penicillin, furesemide,

sulfasalazine, penicicllamine, captopril, sulfasalazine, penicicllamine, captopril, etc, local trauma, burn wounds, grafts, etc, local trauma, burn wounds, grafts, irritants, UV radiation and malignancies irritants, UV radiation and malignancies like carcinoma in stomach can precipitate like carcinoma in stomach can precipitate this diseasethis disease

Erythema MultiformeErythema Multiforme

An acute, self limiting, An acute, self limiting, mucocutaneous reaction pattern mucocutaneous reaction pattern to many viral, bacterial, protozoal to many viral, bacterial, protozoal and fungal infections, tumors, and fungal infections, tumors, drugs, autoimmune states and drugs, autoimmune states and miscellaneous conditionsmiscellaneous conditions

Clincial SpectrumClincial Spectrum

Symmetrically distributed Symmetrically distributed polymorphic rashpolymorphic rash

Target lesions seen on hands with Target lesions seen on hands with a central vesicle or erythema a central vesicle or erythema surrounded by a pale and then a surrounded by a pale and then a red ringred ring

TENTEN

Extensive denudation of skin is Extensive denudation of skin is the hallmark of TENthe hallmark of TEN

Mortality rate – 40 – 50%Mortality rate – 40 – 50% Malaise, pruritis, fever, Malaise, pruritis, fever,

prostration and myalgia are prostration and myalgia are commoncommon

Acute Skin Failure - Acute Skin Failure - ManagementManagement Twin management principlesTwin management principles

– Prompt initiation of appropriate Prompt initiation of appropriate treatmenttreatment

– Excellent double barrier nursing careExcellent double barrier nursing care

Acute Skin Failure - Acute Skin Failure - ManagementManagement

Careful observations onCareful observations on– Heart rateHeart rate– Pulse ratePulse rate– Urinary volume monitored hourly Urinary volume monitored hourly – Urinary osmolarityUrinary osmolarity– GlycosuriaGlycosuria– TemperatureTemperature– Gastric contents monitored 3 – 4 hourlyGastric contents monitored 3 – 4 hourly– Any change in extent of skin lesions and Any change in extent of skin lesions and

body weightbody weight

Acute Skin Failure - Acute Skin Failure - ManagementManagement

Correction and maintenance of Correction and maintenance of hemodynamic equilibrium by fluid and hemodynamic equilibrium by fluid and electrolyte administrationelectrolyte administration

Aggressive nutritional supportAggressive nutritional support Judicious use of antibiotics – to avoid strain Judicious use of antibiotics – to avoid strain

selection, fungal infection and drug selection, fungal infection and drug reactionsreactions

Topical antiseptics like silver sulphadiazineTopical antiseptics like silver sulphadiazine Specific therapy – based on the underlying Specific therapy – based on the underlying

causecause

Summarizing…Summarizing…

Sudden severe alterations in the Sudden severe alterations in the anatomy and physiology of skin anatomy and physiology of skin consequent to generalized consequent to generalized dermatoses can lead to disabling dermatoses can lead to disabling complications complications

Understanding the etiopathogenesis Understanding the etiopathogenesis and their prompt management in ICU and their prompt management in ICU on lines similar to that of burns can on lines similar to that of burns can salvage many livessalvage many lives