Skin lesions in the ICU

Mucocutaneous findings among children in the pediatric intensive care unit at a tertiary care center: A prospective observational study from South India

BACKGROUND/OBJECTIVES

Children admitted to a pediatric intensive care unit (PICU) can present with a variety of skin lesions and the need for dermatology consultation is increasing. Dermatoses in the PICU can be primary or secondary to treatment or underlying systemic illness. Our objective was to study the frequency, pattern, and systemic associations of mucocutaneous findings among children in the PICU.

METHODS

We conducted a prospective, observational study in the PICU of our hospital for 1 year from January 2019 to December 2019. Detailed history, examination, and treatment of consecutive children admitted with mucocutaneous findings were recorded and the results were tabulated and analyzed.

RESULTS

Among 2606 children screened, 11.5% (300/2606) had 314 mucocutaneous manifestations. The male-to-female ratio was 1.3:1 and their ages ranged from 1 month to 15 years (mean age, 4.4 years). Dermatoses belonged to infectious, 41% (124/314), inflammatory, 29.6% (93/314), nutritional, 12.4% (39/314), hematological/vascular malformations, 3.5% (11/314), rheumatological/vasculitic, 3.2% (10/314), neurocutaneous, 0.6% (2/314), and miscellaneous, 11.1% (35/314) groups. Within this cohort, 25.7% (77/300) had a purely dermatological disorder, 28.3% (85/300) had an associated systemic process, 0.7% (2/300) had iatrogenic skin findings, and 45.3% (136/300) had incidental skin findings. On follow-up, 4% (12/300) died, 85% (256/300) improved/recovered, 3% (8/300) were lost to follow-up, and 8% (24/300) did not need active intervention.

CONCLUSION

Our study highlights the frequency of dermatologic disorders among children in the PICU. A notable proportion of patients had primary dermatological disorders or mucocutaneous findings associated with systemic illness.

Oral Complications of ICU Patients with COVID-19: Case-Series and Review of Two Hundred Ten Cases

BACKGROUND

The critically ill patients suffering from coronavirus disease (COVID-19) and admitted to the intensive care units (ICUs) are susceptible to a wide array of complications that can be life-threatening or impose them to long-term complications. The COVID-19 oral mucocutaneous complications require multidisciplinary management and research for their pathophysiological course and epidemiological significance; therefore, the objective of this study was to evaluate the prevalence and characteristics of the critically ill COVID-19 patients with oral complications.

METHODS

We described the clinical and microbiological characteristics of the critically ill COVID-19 patients in our ICU department (Banska Bystrica, Slovakia). In addition, we reviewed the current body of evidence in Ovid MEDLINE^®, Embase, Cochrane Library, and Google Scholar for the oral mucocutaneous complications of ICU patients with COVID-19.

RESULTS

Three out of nine critically ill patients (33.3%) in our ICU department presented with oral complications including haemorrhagic ulcers and necrotic ulcers affecting the lips and tongue. The microbiological assessment revealed the presence of opportunistic pathogens, confirming the possibility of co-infection. On reviewing the current literature, two hundred ten critically ill patients were reported to have oral complications due to their stay in the ICU setting. Perioral pressure ulcers were the most common complication, followed by oral candidiasis, herpetic and haemorrhagic ulcers, and acute onset macroglossia. The prolonged prone positioning and mechanical ventilation devices were the primary risk factors for those oral complications, in addition to the immunosuppressive drugs.

CONCLUSIONS

The multidisciplinary approach is strongly advocated for monitoring and management of COVID-19 patients, thus implying that dermatology and oral healthcare specialists and nurses should be integrated within the ICU teams.

Dermatological Manifestations in the Intensive Care Unit: A Practical Approach

Dermatological problems are not usually related to intensive medicine because they are considered to have a low impact on the evolution of critical patients. Despite this, dermatological manifestations (DMs) are relatively frequent in critically ill patients. In rare cases, DMs will be the main diagnosis and will require intensive treatment due to acute skin failure. In contrast, DMs can be a reflection of underlying systemic diseases, and their identification may be key to their diagnosis. On other occasions, DMs are lesions that appear in the evolution of critical patients and are due to factors derived from the stay or intensive treatment. Lastly, DMs can accompany patients and must be taken into account in the comprehensive pathology management. Several factors must be considered when addressing DMs: on the one hand, the moment of appearance, morphology, location, and associated treatment and, on the other hand, aetiopathogenesis and classification of the cutaneous lesion. DMs can be classified into 4 groups: life-threatening DMs (uncommon but compromise the patient's life); DMs associated with systemic diseases where skin lesions accompany the pathology that requires admission to the intensive care unit (ICU); DMs secondary to the management of the critical patient that considers the cutaneous manifestations that appear in the evolution mainly of infectious or allergic origin; and DMs previously present in the patient and unrelated to the critical process. This review provides a characterization of DMs in ICU patients to establish a better identification and classification and to understand their interrelation with critical illnesses.

Clinical characteristics and treatment outcome of Stevens-Johnson syndrome and toxic epidermal necrolysis

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are erythematous skin lesions with blister formation accompanied by mucosal involvement. These conditions are considered to be life-threatening illnesses. Understanding the clinical presentation, risk factors, treatment options and results will be advantageous for physicians in the management of patients in the future. The aim of the present study was to review and analyze the clinical manifestations, drug implications, treatment and outcome of patients with SJS and/or TEN who had been hospitalized in a tertiary care center. All hospitalized patients with SJS and/or TEN during a 5-year period were retrospectively reviewed. The clinical severity was graded according to the score of toxic epidermal necrolysis (SCORTEN) scale. Clinical symptoms, diagnosis, possible precipitating factors, management and outcome data were collected for analysis. A total of 43 patients (mean age, 49.5 years) were hospitalized and classified into the SJS group (55.8%), SJS/TEN overlap group (20.9%) and TEN group (23.3%). The majority of the patients (90.7%) had mucocutaneous eruptions associated with oral drug administration. Allopurinol, anticonvulsants and antibiotics were the most common causative agents for the mucocutaneous eruption. Twenty-eight patients (65.1%) were treated with corticosteroids. The mortality rate was 6.9%. Comparison between the survival group and the non-survival group revealed that patient age >70 years (P=0.014) and body surface area involvement >20% (P<0.01) were the significant factors associated with mortality. The use of systemic steroids was higher in the survival group in comparison with the non-survival group (65.1 vs. 0%, respectively; P=0.014). The mucocutaneous eruptions in SJS and TEN are mostly caused by medication. With early recognition and treatment, the mortality rate in this study was lower than that in previous reports. Patient age and the area of mucocutaneous involvement were significant factors associated with mortality.

Bullous Lesions After Use of a Commercial Therapeutic Hypothermia Temperature Management System: A Possible Burn Injury?

Therapeutic hypothermia (TH) is a novel technique for improving the likelihood of survival with good neurologic outcome after cardiopulmonary arrest. While commercial temperature management systems (TMS) are intended to facilitate cooling of the body during TH, their operation also involves body exposure to heat. We describe the case of a 72-year-old female postarrest patient who underwent TH using a commercial water-circulating TMS and concurrent continuous renal replacement therapy. The patient developed bullous lesions on the thigh and torso suspected to constitute a scald burn injury from the TMS. Clinicians must be aware of this important adverse event when providing TH, especially in the setting of concurrent hemodialysis therapy.

Dermatological manifestations and relationship to outcomes of patients admitted to a medical intensive care unit: a study from a tertiary care hospital in India

AIM

To determine the prevalence of dermatological manifestations in intensive care unit (ICU) patients and assess its impact on outcomes.

METHODS

This was a prospective cohort study of 1013 ICU patients admitted between December 2009 and April 2011. Patients were categorised following an initial screening (within 48 h) and subsequent daily review as those with dermatological manifestations in association with multisystem disorder (category 1), occurring due to treatment or critical illness (category 2), coincidental lesions (category 3) or primary dermatological conditions needing intensive care (category 4). Outcomes included mortality, duration of ventilation and hospitalisation. Factors associated with mortality were explored using univariate and multivariate analyses.

RESULTS

Dermatological manifestations were observed in 427 (42.2%) patients, predominantly of categories 1 (n=159) and 2 (n=160). Common aetiologies were infections (39.3%) and mechanical, thermal or physical injuries (32.8%). Primary dermatological conditions (n=33) included 21 patients with cutaneous infections, 3 with angioedema, 2 each with pemphigus, toxic epidermal necrolysis and psoriasis, and 1 each with Stevens-Johnson syndrome, drug hypersensitivity syndrome and crusted scabies. The presence of cutaneous lesions increased mortality risk (OR 1.56, 95% CI 1.20 to 2.03) and significantly (p<0.001) prolonged ventilation and hospitalisation. Mortality was higher (p<0.001) in patients in categories 4 (65.6%) and 2 (57.5%) compared to those without manifestations (35.5%). After adjusting for age, Acute Physiology And Chronic Health Evaluation II (APACHE-II) score, ventilation and dialysis, the association between dermatological manifestations and mortality was insignificant (OR 1.37, 95% CI 0.97 to 1.95).

CONCLUSIONS

Dermatological manifestations are common in ICU patients. Their presence may impact mortality and duration of ventilation and hospitalisation.

Evaluation of dermatological consultations of patients treated in intensive care unit

BACKGROUND

Skin disorders which require treatment are a common development in patients treated in intensive care units (ICUs). There are very few prospective studies about skin complications in adult ICUs.

OBJECTIVE

The aim of this study is to evaluate skin disorders in ICU-treated adult patients who were consulted for dermatological problems.

METHODS

Eighty-two of 591 patients admitted to ICUs who were consulted for dermatological problems were included in the study. The correlation between skin complications and associated comorbidities, age, gender and ICU length of stay were analyzed.

RESULTS

Ninety dermatological complications were observed. Cutaneous drug reactions were significantly more frequent in female patients than males (p = 0.020). Candidal intertrigo was more frequent in diabetic patients than in nondiabetic patients (p = 0.042).

CONCLUSION

Patients in ICUs may develop various skin disorders that need to be evaluated by dermatological consultations. Clinical features of the patients, especially gender and comorbidities, may predispose skin complications.

Classification of dermatological disorders in critical care patients: a prospective observational study

PURPOSE

The objective of this study was to identify dermatological disorders detected in the intensive care unit (ICU), to analyze their specific characteristics, and to define a useful classification for intensive care physicians.

MATERIALS AND METHODS

This was a prospective, observational study over a 3-year period (2006-2009) in a mixed ICU. This included all patients presenting with dermatological disorders that were detected at the time of ICU admission or developed along the ICU stay. We recorded the specific characteristics of the disorders and its evolution and treatment, which enabled us to classify the different observed conditions. As general variables, we analyzed demographic factors, the principal diagnosis, ICU procedures, the severity score (Acute Physiology and Chronic Health Evaluation II), length of stay, and mortality.

RESULTS

One hundred thirty-three patients showed at least one dermatological disorder (9.3%) and were classified into (1) preexisting dermatological disorders, (2) life-threatening dermatologic disorders, (3) systemic dermatological disorders, (4) infectious dermatological disorders, (5) reactive dermatological disorders, and (6) others.

CONCLUSIONS

Dermatological disorders are a frequent problem in the ICU, and their recognition is key to set up an appropriate care plan. We propose a classification and description of the different types of dermatological disorders that are most commonly found in ICUs.

Skin lesions in children admitted to the paediatric intensive care unit: an observational study

We analysed, by a prospective observational study over a 3-year period, the frequency and character of dermatological symptoms and diseases in children admitted to a tertiary general paediatric intensive care unit (PICU) of a university hospital. Skin problems were observed in 42 of 1,800 children admitted. There was a large variability in dermatological diseases in the PICU. In the majority (23/42), the skin problem was a dermatological manifestation of an underlying illness that caused admission to the PICU, e.g. infection, vasculitis or drug reaction. In four of the seven children who died, a direct relation between the dermatological disease and the cause of death could be established. Although the number of patients with relevant dermatological problems was limited, we believe that a skilled paediatric dermatologist is able to contribute to the effectiveness of diagnostic and therapeutic processes in paediatric intensive care patients.

Skin diseases in intensive care medicine

Though most dermatoses are not life-threatening, skin diseases play an important role in intensive care medicine. Skin findings in intensive care patients may reflect the underlying disease or be complications of intensive medical care. Most important are drug reactions, infections, bacterial toxin reactions, erythroderma, ANCA-positive vasculitides (such as Wegener granulomatosis) and bleeding disorders.