Dermatology is usually an outpatient specialty seldom requiring admission. However, there are some dermatological conditions which, due to their severity or complications of the condition or treatment, require admission to an ICU. There are also occasions when a dermatological opinion on a patient in the intensive care is sought 1. Skin diseases play an important role in intensive care medicine as skin findings in intensive care patients may reflect the underlying disease or be complications of intensive medical care 2.
There is paucity of data focusing specifically on intensive care dermatology 3. Various studies have considered dermatology from the point of view of the intensive care physician.
Badia et al. 4 have reported on the prevalence of skin disease requiring treatment in 10.4% of patients in an interdisciplinary ICU. Additionally, intensive care patients with additional dermatologic diseases have longer stays in the ICU and higher simplified cute physiology score II than patients with healthy skin.
Clinical evaluation of cutaneous findings is made more difficult by atypical morphology and disease courses caused by the altered immune status of the patient, cofactors such as edematous tissue, long-term immobilization, or external injury 5. In some instances (3%), no clear diagnosis can be made due to the uncharacteristic clinical features 6.
The most important skin diseases seen in an ICU setting are drug reactions, infections, bacterial toxin reactions, erythroderma, vasculitides, and bleeding disorders 2. Primary dermatological diseases such as toxic epidermal necrolysis (TEN) or Stevens–Johnson syndrome (SJS) are life-threatening illnesses requiring intensive care 7. The mortality rate for patients with dermatologic diseases in the ICU was estimated as high as 27.5%, with 39.6% having died before ultimate discharge from the hospital 3. Further, skin manifestations may give clues regarding the underlying disease. A careful study of the prevalence and spectrum of cutaneous manifestations in patients who are critically ill will aid in better understanding of the relationship between skin diseases and critical illness.
This study was undertaken to determine the spectrum and prevalence of dermatological manifestations in patients admitted to the ICU and to evaluate for the association between dermatological manifestations and duration of hospitalization and mortality.
Patients and methods
This prospective study was performed in a 30-bedded ICU of a Tertiary Care Centre in North India after obtaining ethics committee clearance. All the patients admitted to the ICU during the period from February 2015 till August 2016 were evaluated for the presence of cutaneous manifestations. Patients with burns or any surgical cause for admission to the ICU were excluded from the study. Paediatric cases were not included. The data was collected in a prestructured performa, which included patient demographics, primary diagnosis, reason for ICU admission, comorbidities, presence or absence of dermatological manifestations, diagnosis of dermatological manifestations, and laboratory investigations including complete blood count, electrolytes, renal and liver function tests, cultures and serological tests as considered appropriate. Patients with dermatological manifestations were allocated to category A and those without dermatological manifestations were allocated to category B. In patients belonging to category A, skin scrapings, swabs for bacterial culture, and biopsies were taken as and when required to reach a definitive diagnosis. Patients of category A were further classified accordingly under four groups as follows:
- Group 1: primary dermatological diseases requiring intensive care.
- Group 2: multisystem disorders or any other primary reason requiring admission to the ICU with cutaneous manifestations.
- Group 3: skin manifestations as a consequence of critical illness or treatment.
- Group 4: skin manifestations unrelated to the ICU.
Minor insignificant lesions such as melasma, acne, melanocytic nevi, etc. were not included.
Analysis of the data was done using the statistical package for the social sciences IBM SPSS statistics for Windows, version 20.0 (Armonk, New York, USA). Pearson’s χ2-test was performed on the data. Test results were evaluated at a confidence interval limit of 95% and a P value of less than 0.05 was considered statistically significant.
The present study was conducted over a period of 19 months from February 2015 to August 2016 in a tertiary center. A total of 946 patients were evaluated during this period, out of which 312 (32.9%) patients had dermatological manifestations (category A) and 634 (67.0%) did not have any cutaneous manifestations (category B). The mean age was 49.6±14.1 years (range: 20–78 years). The prevalence of dermatoses was significantly higher among patients older than 40 years (P=0.001). There was male preponderance in both categories (P≤0.001) (Table 1).
Upon further classification of patients in category A, the highest proportion belonged to group 3 (13.2%), indicating that most of the cutaneous manifestations in the ICU setting are because of immunocompromised status of the patients and 11.5% patients had skin manifestations in association with serious (group 2) underlying multisystem disorders like chronic renal disease, with additional comorbities like diabetes, ischaemic heart disease, or chronic liver disease. Group 1 (3.5%) showed the least proportion of patients indicating few dermatological emergencies like erythroderma or SJS/TEN requiring admission to the ICU. Patients subdivided into group 4 (4.6%) did not have any corelation with their medical condition for admission nor the cutaneous features altered their prognosis or length of stay.
The dermatoses in each group are summarized in Table 2 with the frequency at which they were observed indicating that most cases in group 1 were because of drug reactions manifesting in the form of TEN (Fig. 1), SJS, angioedema, and DRESS secondary to phenytoin and penicillin. The cases of SJS reported were due to phenytoin, allopurinol, valproate, and NSAIDS. These conditions were associated with significant mortality (three out of seven patients). Other etiologies in this group were of acute skin failure as a consequence to vesiculobullous disorders or erythroderma. In group 2, the most common dermatoses were infections (pyodermas, candida, necrotizing fasciitis etc.) (Fig. 2) leading to increased morbidity in critically ill patients followed by cutaneous complications of systemic disorder such as diabetic foot ulcers, necrobiosis lipoidica, and perforating disorders.
In group 3, the salient manifestations were friction blisters (Fig. 3) and pressure sores (Fig. 4) owing to prolonged stay in the same posture, whereas other complaints like purpura resulted from steroid abuse, or as a consequence to drugs used during treatment in the ICU.
Cutaneous examination of the admitted patients showed various types of lesions, which were classified according to the primary lesion type and secondary morphological changes. The most common morphology observed was the maculopapular type (18.2%) owing to drug rashes and dermatitis followed by purpuric and petechial lesions (15.7%) and vesiculobullous (5.04%) lesions. The other noted skin lesions were ulcers, nodules, plaques, etc.
Cutaneous disorders were also categorized based on etiology as shown in Table 3. The most common dermatological manifestations were those secondary to infections (27.5%) followed by immune causes (27.2%).
The average duration of length of stay in the ICU was 10 days. Patients belonging to category A had significantly longer duration of stay (P≤0.001) and significantly higher mortality (P=0.018) than those in category B (Table 1).
Skin manifestations are commonly encountered in ICU patients posing therapeutic and diagnostic difficulty to the physician. Thus, there is a need to evaluate the impact of skin diseases on the overall outcome of the patient. In this prospective study, 946 patients admitted in the ICU were evaluated over a period of 19 months. The prevalence of cutaneous manifestations was 32.9% suggesting that cutaneous involvement is not infrequent in ICU patients. The most frequent cutaneous manifestations were due to critical illness or treatment (13.2%) followed by those associated with multisystem disorder (11.5%). At present, only few studies have been conducted to establish the link between skin manifestations and prognosis of ICU patients. Various studies have demonstrated that proportion of cutaneous manifestations in the adult ICU population varies from 0.47 to 42.2% 3,8. Lower prevalence in few studies, as in a study by Dunnill et al.1, is attributed to a retrospective study design in which there is limitation of screening all the cases with cutaneous findings. In another study by George et al.3, only primary skin conditions directly requiring admission to the ICU were included and skin manifestations associated with systemic diseases were completely ignored. Similarly, a study conducted by Badia et al.4 excluded patients with friction blisters, pressure sore, or other skin disorders not directly influencing the patient’s condition. However, in the present prospective study, all the ICU patients were thoroughly screened and cutaneous manifestations were precisely grouped based on the etiology and morphology of the lesions. Higher proportions might also be due to the difference in clustering of cases in different parts of the world or meticulous examination for including even minor skin diseases. The salient feature of this study was to highlight the common skin manifestations in the ICU and how they influence the prognosis and length of stay.
Serious dermatological conditions requiring admission to the ICU include TEN, SJS, erythroderma, and vesiculobullous diseases 9,10. Most cases of TEN reported in this study were due to various antibiotics and antiepileptics. Drug reactions are dermatological emergencies as they require timely recognition and immediate halting of the offending drug 11. The average reported mortality rate in TEN is 25–35% 9. Consistent with this finding, the mortality rate in TEN was 42.8% in this study. Methotrexate is a widely used drug in dermatology for various indications like psoriasis, pemphigus, and eczema 12. Overdosage or inappropriate prolonged usage of the drug is associated with toxicity involving both mucocutaneous and systemic manifestations 13. Two patients of psoriasis in this study developed oral ulcerations, flaring of plaques with severe constitutional features with high serum methotrexate levels, diagnostic of methotrexate toxicity, culminating in mortality in one of them. Skin failure is defined as inability to maintain core body temperature with percutaneous fluid loss leading to fluid and electrolyte imbalance 14. Most cases of skin failure in our study were due to pemphigus. Secondary infections and immunosuppression due to biologics and long-term steroid use are common complications of pemphigus requiring admission to the ICU. In the present study, there were three deaths from a total of nine patients of pemphigus admitted in the ICU accounting for a mortality rate of 33.3% which is in concordance with other similar studies 15.
Infective etiology was the most common cause of skin manifestations seen in 27.5% of the patients consistent with the study conducted by Prashanth et al.16, in which the prevalence of skin infections was 34.5%. Most of the skin infections were due to staphylococcus aureus followed by fungal etiology. The use of multiple antibiotics causes alteration of normal biologic flora 17,18, which is the leading cause for candida oral thrush observed in ICU patients. Patients in the ICU who are immunocompromised due to various reasons are more prone to reactivation of herpes simplex and zoster infections as reported in this study.
Multisystem disorders such as diabetes, systemic lupus erythematosus, scleroderma, and chronic renal failure have characteristic cutaneous manifestations 19. In diabetic patients, there is delayed healing of ulcers, xerosis, and characteristic necrobiosis lipoidica involving shins. Chronic renal failure is associated with an array of skin manifestations such as ichthyosis, pruritus and xerosis 20. The most frequently reported findings of this study were xerosis followed by acquired perforating disorders. Such cutaneous findings serve as subtle signs in diagnosing the underlying systemic disease.
Majority of the dermatological manifestations in the ICU occur as a consequence of critical illness, intensive treatment, and invasive life-support procedures required 21. Owing to the immobility in severely ill patients they are more prone to pressure sores and friction blisters 22. Healing is further delayed in bed sores due to compromised blood supply, protein–calorie malnutrition and frequent exposure to stool and urine. Frequent repositioning is advised to avoid bed sores. Invasive procedures like central venous pressure monitoring and intubation are frequent reasons for purpura in senile individuals admitted in critical care units. Nutritional deficiencies and fragility of capillaries are additional contributing factors to the development of purpura.
Altogether, these cutaneous diseases have significant impact on mortality and length of stay in ICU as patients with dermatological diseases in our study were more critical than those who did not have any skin problem. However, the shortcoming of the present study was the inability to calculate morbidity with adequate scoring systems like acute physiology and chronic health evaluation scoring 23. Furthermore, the relevance of exhaustive classification and inclusion of even those skin manifestations which are minor or unrelated to ICU such as vitiligo, keloid, and others is still doubtful.
Dermatological diseases, frequently encountered in ICU patients, are often a pointer toward the underlying systemic disease and have a significant influence on the duration of hospitalization, morbidity, and mortality.
Conflicts of interest
There are no conflicts of interest.
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