Skin lesions in the ICU

Intensive Care Med (1999) 25: 1271±1276 Ó Springer-Verlag 1999 M. Badia J. Trujillano E. Gascó J.-M. Casanova M. Alvarez M. León Received: 7 April 1999 Accepted: 30 August 1999 ) M. Badia ( ) ´ J. Trujillano ´ E. Gascó ´ M. Alvarez ´ M. León Intensive Care Unit, Hospital Universitario Arnau de Vilanova, C/ Rovira Roure 80, E-25198 Lleida, Spain e-mail: fiturbe@arnau.scs.es Tel.: + 34-9 73 24 81 00 Fax: + 34-9 73 24 87 54 J. M. Casanova Department of Dermatology, Hospital Universitario Arnau de Vilanova. C/ Rovira Roure 80, E-25198 Lleida, Spain Address for correspondence: M. Badia Castelló, C/ Bisbe Meseguer 1, 30, 2a, E-25003 Lleida, Spain, e-mail: marionabadia@mx3.redestb.es, Tel.: + 34-9 73 26 69 30 O R I GI N A L Skin lesions in the ICU Abstract Objective: The objective of this study is to identify the dermatological disorders (DDs) responsible for the most common skin lesions in the ICU, their incidence and their impact on mortality, degree of severity and length of stay in the ICU. Design and setting: We performed a 2-year prospective study in a general medical and surgical ICU including, exceptionally, paediatric cases. Patients: We included all patients who presented skin lesions upon admission or developed them during their ICU stay. Results: Forty-six patients (10 % of all admissions) were enrolled, with 51 DDs. SAPS II score (43) and mean length of stay (19 days) were significantly higher than in the gen- Introduction Only rarely does dermatological pathology require ICU admission. However, certain dermatological problems such as erythroderma, bullous diseases or dermatological infections may become severe due to the loss of cutaneous functions which, fundamentally in the stratum corneum, prevent the entry of certain microorganisms and toxins, protect against ultraviolet light injury and help to maintain body temperature and hydroelectrolytic homeostasis [1]. The term ªacute dermatological insufficiencyº has been coined to refer to circumstances in which the severity of the dermatological disorders (DDs) may lead to multiple systemic complications and become life-threatening [2, 3]. Situations in which the skin lesion is a manifestation of a systemic disease or a eral group of ICU admissions. Differences in mortality rates (26 % versus 29 %) were not statistically significant. Conclusions: DDs are entities that should be borne in mind in the critically ill patient; their incidence is by no means negligible and makes careful examination of the skin mandatory both on admission and during a patient's ICU stay. Key words Skin diseases ´ Intensive care ´ Critical illness ´ Dermatology complication in the critically ill patient are relatively common [4]. In the context of critical illness, the skin is the organ that is most frequently forgotten and skin lesions are often ignored in daily clinical examination. This 2- year prospective and descriptive study included all patients who presented or developed a DD on admission or during their stay in the ICU which required exploration, diagnosis and, in some cases, treatment. Material and methods We designed a dermatological record with three main sections: (1) general, including demographical data and cause of admission, (2) specific, describing the characteristics of the lesion, clinically rele- 1272 vant aspects and the evaluation of a dermatologist with diagnosis and therapeutic recommendations and (3) topographic, giving an idea of the location and extension of each lesion. Table 1 Characteristics of patients with Dermatological Disorders in ICU Patient selection Sex (M/F) Age (years) Length of stay (days) SAPS-II score Medical / surgical (%) Mortality ICU (%) This prospective study was carried out over a period of 2 years (February 96±February 98) in the ICU of the hospital Universitario Arnau de Vilanova de Lleida in Spain. Inclusion criteria were as follows: all consecutive patients who, upon admission or during their course in the ICU, developed a DD that required diagnosis or treatment due to its characteristics or possible clinical repercussions. Exclusion criteria were pressure sores, burns and DDs considered to be irrelevant in the context of the patient. Informed consent to photograph the lesions was obtained from the patient or family members. The ethical committee was not contacted, because of the observational nature of the study. Statistical method Data are given as the mean and standard deviation unless otherwise specified. For statistical analysis Student's t-test and chisquare tests were used. A result was considered to be significant at p less than 0.05. Results During the study period 51 DDs were recorded in a total of 46 patients, representing 10.4 % of all admissions to the ICU in that period (Table 1). Thirty patients were DD GENERAL p n = 46 30 / 16 46 ± 25 19 ± 28 43 ± 18 70 / 30 26 n = 442 322 / 140 53 ± 21 9 ± 13 37 ± 19 72 / 28 29 NS NS SS SS NS NS Values are mean ± SD DD dermatological disorders, GENERAL general group without DD, NS without Statistical Significance, SS Statistical Significance male and 16 female. The mean age was 46  25 years (range 1±82 years). The mean length of stay of patients with a DD was 19  28 days versus 9  13 days. Mortality in the DD group was 26 % versus 29 % in the general group. SAPS II score was calculated to estimate the degree of severity. The mean SAPS II score in the study group was 43  18 versus 37  19 in the general group. Statistically significant differences (p < 0.05) were found in length of stay (longer for the study group) and degree of severity (higher for the study group). The DDs were classified into vascular disease-related dermatitis, drug reactions, infections, contact and previous DDs (Table 2). Time of onset of lesions depended on the aetiology, and so the lesions derived from a peripheral vascular disease or another previous Table 2 Classification of the Dermatological Disorders (Peripheral VD peripheral vascular disease, Previous D dermatological disorders previous to admission in ICU) n (%) DIAGNOSES APPEAR 14 CLINICALb TREAT F NF EX 12 / 14 Peripheral VD 14 (27) Infectious 0 0 0 2 / 14 1 / 14 Drug reaction 11 (21) Infectious Miscellaneous Surgery Trauma 4 4 1 2 11 ± 9a 3±3 11 ± 0 21 ± 1 1/4 0 0 0 1/4 0 0 1/2 4/4 4/4 1/1 2/2 0 0 0 0 2/4 2/4 1/1 1/2 Infections 18 (35) Infectious COPD Miscellaneous Surgery Trauma 2 6 4 3 3 5±1 14 ± 12 6±8 12 ± 5 15 ± 17 1/2 1/6 0 2/3 0 2/2 6/6 4/4 3/3 3/3 1/2 4/6 4/4 2/3 3/3 1/2 2/6 0 1/3 0 1/2 3/6 0 0 0 Contact 5 (10) Previous D 3 (6) Infectious COPD Miscellaneous Surgery Miscellaneous Surgery 1 1 1 2 2 1 2±0 1±0 4±0 9±5 0±0 0±0 0 1/1 1/1 1/2 0 0 0 1/1 1/1 1/2 1/2 0 1/1 1/1 1/1 2/2 1/2 0 0 0 0 0 1/2 1/1 0 0 0 0 0 1/1 APPEAR delay in the appearance of lesions from the admission in the ICU, CLINICAL clinical manifestations, TREAT treatment (lesions that needed specific and / or symptomatic treatment), F favourable, NF not favourable (lesions that either do not improve or worsen), EX patients who died with skin lesions whose evolution not be evaluated, DIAGNOSES patients are subdivided into: Sur- gery, Trauma, Infectious diseases, COPD and Miscellaneous (medical conditions not include previously) Values are number of patients / total a (days) mean ± SD b If the patient was sedaded it was considered symptomless 1273 Meningococcal septicaemia Fig. 1 Necrotic purpuric rash in meningococcal septicaemia pathology were present or closely related to the cause of admission. In allergic contact dermatitis, the lesions appeared early, while in the infectious disorders they tended to appear in the long-stay patients. Most lesions were asymptomatic; in some cases the symptoms could not be assessed, because of the use of sedation. The lesions required aetiological treatment if they were infectious in origin, and symptomatic treatment if there were related clinical manifestations. Evolution was favourable in survivors, except when the dermatological condition was present prior to admission. One case secondary to a peripheral vascular disorder needed surgical treatment (Table 2). Twelve patients were admitted with the probable diagnosis of meningococcal sepsis. The skin lesions were of considerable help in establishing the diagnosis. These lesions are the result of local endothelial injury thrombosis and necrosis of the vascular walls. In vascular lesions, immunoglobulins, complement and bacteria can be detected inside the endothelial cells. Gram stain of the biopsy or aspiration of the lesions may show meningococci [5]. The most characteristic skin lesions are small and irregular petechiae (Fig. 1), normally located in the extremities and trunk, and sometimes affecting mucosa. However, in our series it is remarkable that there were five cases in which lesions were extensive and confluent with ecchymoses correlating with higher levels of severity. Early diagnosis is crucial in this disease in order to initiate possibly life-saving treatment. Ecthyma gangrenosum One patient was admitted for septic shock of unknown aetiology and neutropenia. On examination, we noted the presence of multiple purple maculae in the trunk and gluteal region which evolved to necrotic nodules with a central black lesion. The appearance of this type of lesion may be an early sign of septicaemia due to Pseudomona aeruginosa, especially in immunosuppressed patients: antipseudomonal treatment should therefore be initiated [6]. Discussion All DDs identified in the ICU over a period of 24 months were studied and classified in five categories, according to aetiology. Peripheral vascular disorder-related dermatitis In patients with a systemic infectious disease, skin microcirculation may be affected by direct vascular injury or hypersensitivity reactions which give rise to characteristic cutaneous manifestations that can aid early diagnosis. The diagnosis of the lesions in our cases was clinical, confirmed by the detection of the microorganism involved. Treatment was aetiological with improvement of the lesions except in one case of meningococcal septicaemia in which the third phalanx of the finger had to be amputated due to necrosis. Endocarditis One patient was admitted for acute endocarditis secondary to Streptococcus viridans infection and presented hemorrhagic macular lesions on palms and soles, approximately 2±4 mm in diameter, defined as Janeway's lesions due to septic microemboli in subcutaneous tissue [7]. Cutaneous reactions to drugs Many drugs induce cutaneous reactions, the most frequent being urticarial lesions and morbilliform eruptions. The mechanism underlying the two reactions is uncertain. In many cases it is not easy to establish reliably that the drug is the cause of the cutaneous problem [8]. In these circumstances it is mandatory to evaluate the clinical aspect of the lesions, the knowledge of the possible drugs involved and the resolution after withdrawal of the drug if possible. We did not perform in vitro study of lymphocyte toxicity or a migration inhibition 1274 factor testing in any of our cases. In our series the drugs involved were imipenem, ciprofloxacin, vancomycin, cefepime, aztreonam and piperacillin-tazobactam. In all cases there was an improvement after drug administration was stopped. Urticaria Urticaria is characterized by pruritic red wheals of variable size. It is an immediate hypersensitivity reaction. The fact that the lesion may appear a few minutes after exposure to the drug facilitates diagnosis. Four patients developed urticarial lesions. Fig. 2 Erythematous lesions with centrifugal progression localized in the inguinal region and caused by Candida Morbilliform reaction Seven patients showed a morbilliform eruption with erythematous maculopapules, often confluent. These eruptions began characteristically in the trunk or in pressure or traumatic areas 1 week after initiation of treatment and persisted for 1±2 weeks. After discontinuation of the drug the lesions vanished, but in several cases they also disappeared even though the drug responsible was not withdrawn. Re-exposure to the drug does not invariably cause recurrence of the lesions, and so the hypothesis of a hypersensitivity mechanism remains uncertain. Infectious dermatological disorders Under this heading we classified DDs provoked by fungi, bacteria or viruses. The skin is in continuous contact with pathogens. The appearance of a cutaneous infection depends on several factors, microorganism-dependent as well as host-dependent. Dermatomycosis Candida is the commonest type of dermatomycosis and was the causative fungus in our ten cases. Candida can affect skin, mucosa and annexes; the most common pathogenic form in humans is the albicans species. Fungus can be found in a saprophytic form and the conversion to the pathogenic form depends upon a series of factors often encountered in the critically ill patient, i. e. local (humidity, maceration, temperature, etc.) or general factors (diabetes, corticoids, in-dwelling catheters, etc.). These factors favour the appearance of mucocutaneous candidiasis. The cutaneous folds (submammalian, genitocrural and subaxillary regions) are the most frequent sites (Fig. 2). The main features are erythematous and macer- ated areas in intertriginous regions that progress centrifugally as vesicles and pustulae. One case was a cutaneous expression of a disseminated candidiasis. In three cases the diagnosis was confirmed by positive cultures and in the others the diagnosis was only clinical. These lesions were treated with topical potassium permanganate, followed by topical clotrimazole. Pyoderma Like fungi, bacterial infections of the skin are associated with both local and general factors. The most frequently encountered bacteria are streptococci and staphylococci, and the most common pyoderma is impetigo, found in four of our patients. Impetigo begins in pressure zones and folds in the form of vesicles and pustulae located between the corneal and granulosum stratum near a hair follicle, and exude a yellowish liquid after rupture. One case was confirmed by culture which identified Staphylococcus aureus (Fig. 3). In the other cases, diagnosis was clinical with confirmation by a dermatologist on the basis of the morphology of the lesions. The lesions were treated topically with chlorhexidine. Herpes virus infections The herpes virus group includes eight members. A feature of infection is the absence of virus elimination and its persistence as a latent infection becoming reactivated under certain conditions [9]. Four patients showed herpetic lesions. Herpes simplex 1 and 2. One patient developed a herpetic lesion in the nasolabial region with a wide erythematous area covered with vesicles, which evolved towards ulceration and crusting. It was treated topically 1275 Fig. 3 Subcorneal bullae followed by an exudative erosive lesion in pyodermitis Fig. 4 Disseminated lesions in different stages during varicella infection with acyclovir. Another patient, admitted for meningococcal sepsis, presented ulcerated lesions with a white exudate and some vesicles in the genitocrural region during the convalescence period, together with painful inguinal adenopathies compatible with recurrent herpes genitalis infection. If treatment is needed, oral acyclovir is the drug of choice although recurrent infection responds less well than primary infection. Previous dermatological disorders Zoster. A third patient presented vesicles distributed in clusters in the trigeminus nerve zone; zoster with ophthalmic involvement was diagnosed. Treatment was initiated with oral and topical acyclovir and symptomatic measures. Varicella. The fourth patient was a school bus driver who was admitted for severe acute respiratory failure secondary to a varicellous pneumonia, the most severe and frequent complication of varicella primary infection [10]. The cutaneous involvement of the disease was typical, with the appearance of a disseminated eruption, predominantly in the trunk, with lesions at each stage, from maculae to papules, pustulae and crusting (Fig. 4). The patient was treated with systemic gancyclovir and supportive measures. Allergic contact dermatitis Contact dermatitis, or eczema, is a reaction of cutaneous intolerance to exogenous or endogenous agents. It is one of the most frequent DDs and is due to superficial inflammatory dermatitis secondary to contact with an allergen. In our study, five cases required symptomatic treatment and withdrawal of the allergen due to the scale and extension of the lesions. The causative allergens were electrode paste, dressings, chlorhexidine and a fifth unknown agent. Three patients presented with histories of dermatological disease on admission: neurofibromatosis, tuberous sclerosis and elephantiasis nostras. The last of these required treatment to control the problem. In conclusion,a common feature of critically ill patients affected with DDs was a significantly longer ICU stay than the other patients admitted during the same time period (p < 0.05). The SAPS II score was significantly higher, but there was no increase in mortality. Our results suggest that critically ill patients present a higher degree of severity and longer ICU stay; this favours the appearance of DDs, especially infectious ones. The DDs identified in the ICUs include a wide range of situations, as noted by Dunnill et al. [11]: (1) situations in which the lesion is closely associated with an acute systemic disorder, and its identification helps diagnosis. The most outstanding case is the cutaneous lesion associated with infectious disorders (meningococcal sepsis, endocarditis, etc.); (2) situations in which the skin lesions appear concomitantly with the main disease without worsening it or changing its course, but requiring specific or symptomatic treatment (dermatomycosis and cutaneous infectious lesions in general); (3) DDs as undesired reactions to treatment (allergic contact dermatitis and drug reactions) and (4) previous DDs unrelated to the cause of admission to the ICU. The great variety of cutaneous problems means that a patient's clinical examination in the critical care setting must include systematic exploration of the skin to detect all the problems that may begin either at admission or at any moment during the course of the illness [12]. In the ICU environment the patient undergoes multiple manipulations (monitoring, vascular accesses, etc.), which complicate both the diagnosis and treatment of these disorders in many circumstances [13]. 1276 DDs can be decisive in diagnosis, and therefore deserve considerable attention [14]. The role of the dermatologist is particularly important as regards correct diagnosis and the use of specific treatments. Finally, we should stress that in our series 10 % of the patients presented a DD. We now plan to produce a dermatological atlas specific for critical care, and would greatly appreciate collaboration from other ICUs interested in participating in this project. Acknowledgements The authors thank Mr. Mike Maudslay, Universidad de Barcelona, for English correction of the manuscript. References 1. Jackson SM, Elias PM (1993) Skin as an organ of protection. In: Fitzpatrick TB, et al. (eds) Dermatology in General Medicine. 4th edn. Mc Graw-Hill, New York, pp 241±253 2. 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