Dermatologic Conditions in
The Critically Ill
Critical Functions of The Skin
Barrier function: water and electrolytes
Mechanical protection
Perform wound repair
Immune ...
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...
Life-threatening Dermatologic Conditions
Toxic epidermal necrolysis (TEN)
Pemphigus vulgaris
Pustular psoriasis
Exfoliativ...
Toxic Epidermal Necrolysis
Widespread erythema and epidermal
sloughing
Many etiology factors (drug reactions:
sulfonamides...
Toxic Epidermal Necrolysis
- Clinical Manifestations -
Early TEN: indistinguishable from EM, drug
reaction, SSSS, chemical...
Toxic Epidermal Necrolysis
- Complications -
Hypovolemia
Septic shock
Pulmonary edema, renal failure
GI bleeding
Tracheiti...
Toxic Epidermal Necrolysis
- Treatment -
Adequate supportive care
High-dose corticosteroid (prednisolone
250mg/day): contr...
Pemphigus Vulgaris
Autoimmune disease
4th
to 5th
decades
Flaccid bullae
Nikolsky’s sign (+)
Diagnosis: skin
biopsy with DI...
Pemphigus Vulgaris
- Treatment -
Topical wet dressing
with normal saline
Prednisolone
240mg/day
Adjuvant therapy:
methotre...
Pustular Psoriasis
Generalized erythroderma and
pustules
Provocative factors: infection,
pregnancy, sunlight, drugs (salic...
Pustular Psoriasis
- Clinical Manifestations -
Waves of pustules
and corneal exfoliation
Exacerbation of
polyarthritis
Leu...
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
idiop...
Erythema Multiforme
Target lesions
EM minor vs. EM major (Stevens-
Johnson syndrome)
A delayed hypersensitivity reaction
M...
Erythema Multiforme
Complications
 10% visual impairment
 Evolution to TEN
 Mucosal damage
 Pneumonia: 18% of
death
Tr...
Dermatologic Complications of
Critically Ill Patients
Drug reaction
Contact dermatitis
Decubitus ulcer
Steroid acne
Asteat...
Drug Reaction
Mechanism unknown
Incidence 3/1000
2/3 caused by
sulfonamides,
penicillins, and blood
products
Typical rashe...
Contact Dermatitis
Irritant dermatitis
strong alkalis, acids, frequent wash
allergic contact dermatitis
Para-aminobenzoid ...
Decubitus Ulcer
Pelvic area, legs
Rish factors:
pressure, fracture,
fecal incontinence,
urinary catheter,
weight loss,
hyp...
Steroid Acne
Uniform, small
papules and pustules
on neck, chest and
back
NOT a
contraindication to
continued use of oral
s...
Asteatotic Eczema
In elderly, atopy
Anterolateral aspect
of legs
Wet dressing then
lubrication with
petrolatum or lanolin
...
Miliaria
Heat rash
Eccrine duct
occlusion
Miliaria crystallina
Miliaria rubra
Tx: skin ventilation,
change bed linen
Selected Conditions with
Distinctive Cutaneous Findings
AIDS
Subacute bacterial
endocarditis
Sepsis
Purpura
Malignant infi...
Subacute Bacterial Endocarditis
Petechia
Splinter hemorrhage
Osler nodes
Janeway lesions
Sepsis
Neisseria gonorrhoeae
crops of tender hemorrhagic papules near
joints, <10 lesions
Neisseria meningitidis
headache,...
Purpura
Senile purpura
Drug purpura
ampicillin,
chlorothiazide,
phenylbutazone,
sulfonamides
Purpura fulminans
gr. A strep...
Herpes Simplex and Zoster
Severe complication
esophagitis,
pneumonitis,
hepatitis,
gastroenteritis,
encephalitis
Immunocom...
Herpes Simplex and Zoster
- Treated with Acyclovir -
Indications
~ Immunocompromised
~ trigeminal or sacral
nerve (zoster)...
Cutaneous Necrotizing Vasculitis
Leukocytoclastic
vasculitis
Palpable purpura
Coexisting chronic
disease, infection,
drugs...
Bullous Pemphigoid
Age 50-70y/o
Large, tense bullae,
urticarial or
erythematous base
Inner thigh, axillae,
groin, elbow, l...
Quiz 1-4
Quiz 7-8
Dermatologic Conditions in The Critically Ill
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Dermatologic Conditions in The Critically Ill

  1. 1. Dermatologic Conditions in The Critically Ill
  2. 2. Critical Functions of The Skin Barrier function: water and electrolytes Mechanical protection Perform wound repair Immune function Maintain body temperature
  3. 3. Loss of Barrier Function Massive fluid and electrolyte loss Profound calorie loss Invasion of microorganism hypothermia
  4. 4. 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
  5. 5. Life-threatening Dermatologic Conditions Toxic epidermal necrolysis (TEN) Pemphigus vulgaris Pustular psoriasis Exfoliative dermatitis Erythema multiforme
  6. 6. Toxic Epidermal Necrolysis Widespread erythema and epidermal sloughing Many etiology factors (drug reactions: sulfonamides, butazones, hydantoins) Immune mechanism High morbidity and mortality
  7. 7. Toxic Epidermal Necrolysis - Clinical Manifestations - Early TEN: indistinguishable from EM, drug reaction, SSSS, chemical burn Prodromal symptoms: skin tenderness, conjunctiva burning, fever, malaise, arthralgia Morbilliform rash begins on face and limbs Followed by vesicles, bullae, rupture of bullae, denuded skin up to 50% BSA or more Nikolsky’s sign (+) Severe mucous membrane involvement
  8. 8. Toxic Epidermal Necrolysis - Complications - Hypovolemia Septic shock Pulmonary edema, renal failure GI bleeding Tracheitis, bronchopneumonia Acute tubular necrosis, membranous glomerulitis
  9. 9. 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
  10. 10. Pemphigus Vulgaris Autoimmune disease 4th to 5th decades Flaccid bullae Nikolsky’s sign (+) Diagnosis: skin biopsy with DIF, IIF Serum IgG titer
  11. 11. Pemphigus Vulgaris - Treatment - Topical wet dressing with normal saline Prednisolone 240mg/day Adjuvant therapy: methotrexate, azathioprine, cyclophosphamide, gold
  12. 12. Pustular Psoriasis Generalized erythroderma and pustules Provocative factors: infection, pregnancy, sunlight, drugs (salicylate, iodide, lithium, phenylbutazone), sudden withdrawal of systemic corticosteroids
  13. 13. Pustular Psoriasis - Clinical Manifestations - Waves of pustules and corneal exfoliation Exacerbation of polyarthritis Leukemoid reaction, hypoalbuminemia
  14. 14. Pustular Psoriasis - Treatment - Topical low-potency steroid bland emollient PUVA Etretinate methotrexate
  15. 15. Exfoliative Dermatitis Generalized erythema and scaling Associated with preexisting dermatoses, malignancy, drugs or idiopathic Tx: underlying disease
  16. 16. Erythema Multiforme Target lesions EM minor vs. EM major (Stevens- Johnson syndrome) A delayed hypersensitivity reaction Many etiologic factors: herpes, mycoplasma, drugs….etc.
  17. 17. Erythema Multiforme Complications  10% visual impairment  Evolution to TEN  Mucosal damage  Pneumonia: 18% of death Treatment: systemic steroid?
  18. 18. Dermatologic Complications of Critically Ill Patients Drug reaction Contact dermatitis Decubitus ulcer Steroid acne Asteatotic eczema Miliaria Cutaneous dopamine infusion complication
  19. 19. Drug Reaction Mechanism unknown Incidence 3/1000 2/3 caused by sulfonamides, penicillins, and blood products Typical rashes: urticaria, angioedema, and morbilliform rash Latency: within 36 hours to a few weeks Treatment: discontinue responsible drugs
  20. 20. Contact Dermatitis Irritant dermatitis strong alkalis, acids, frequent wash allergic contact dermatitis Para-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
  21. 21. Decubitus Ulcer Pelvic area, legs Rish factors: pressure, fracture, fecal incontinence, urinary catheter, weight loss, hypoalbuminemia Manage according to the classification
  22. 22. Steroid Acne Uniform, small papules and pustules on neck, chest and back NOT a contraindication to continued use of oral steroid
  23. 23. Asteatotic Eczema In elderly, atopy Anterolateral aspect of legs Wet dressing then lubrication with petrolatum or lanolin Topical steroid ointment or cream
  24. 24. Miliaria Heat rash Eccrine duct occlusion Miliaria crystallina Miliaria rubra Tx: skin ventilation, change bed linen
  25. 25. Selected Conditions with Distinctive Cutaneous Findings AIDS Subacute bacterial endocarditis Sepsis Purpura Malignant infiltrate Herpes simplex and zoster Cutaneous necrotizing vasculitis Bullous pemphigoid Disseminated candidiasis SLE Osler-Weber-Rendu syndrome Porphyria cutanea tarda Carbon monoxide Necrolytic migratory erythema Erythema chronicum migrans
  26. 26. Subacute Bacterial Endocarditis Petechia Splinter hemorrhage Osler nodes Janeway lesions
  27. 27. Sepsis Neisseria gonorrhoeae crops of tender hemorrhagic papules near joints, <10 lesions Neisseria meningitidis headache, nausea, vomiting, fever; hemorrhagic rash, stupor Pseudomonas aeruginosa hemorrhagic vesicle, ecthyma gangrenosum, gangrenous cellulitis, nodular cellulitis
  28. 28. Purpura Senile purpura Drug purpura ampicillin, chlorothiazide, phenylbutazone, sulfonamides Purpura fulminans gr. A streptococcal infection, scarlet fever, staphylococcal and pneumococcal bacteremia, meningococcemia, varicella
  29. 29. Herpes Simplex and Zoster Severe complication esophagitis, pneumonitis, hepatitis, gastroenteritis, encephalitis Immunocompromise patients
  30. 30. 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
  31. 31. Cutaneous Necrotizing Vasculitis Leukocytoclastic vasculitis Palpable purpura Coexisting chronic disease, infection, drugs, idiopathic
  32. 32. 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
  33. 33. Quiz 1-4
  34. 34. Quiz 7-8
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