1. EMERGENCIES IN DERMATOLOGY
Acute Skin Failure

2. ICU in the Skin department
Prof Rene Touraine first established an ICU in the skin Dept. in 1974
Now recognized as a necessity due to large number of extensive skin diseases eventuating into the potentially fatal syndrome of ‘acute skin failure’

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

4. Consequences Disfiguring dermatoses can generate emergency situations
Disproportionate and spectral psychocutaneous morbidity
Disruption of psychosocial function of self worth and emotional expression
Disrupt interconnected anatomy and physiology of skin

5. Emergencies Anaphylactic Exanthematous Acute eczematous
Urticarial / angioedematous
Purpuric
Photosensitive reactions
SJS - TEN

6. Emergencies in New born
Purpura fulminans
Lamellar desquamation
Infantile acute hemorrhagic oedema
Sclerema neonatorum
Congenital absence of skin and metabolic disorders like porphyrias

7. Etiopathogenesis
Failure of skin to perform its multiple functions can lead to
Acute failure of heart, lung, kidney and death consequent to structural and functional alterations in various components of the skin

8. Stratum Corneum Destruction of Stratum corneum
Increase in fluid loss by 40 times
50% of BSA involvement leads to daily fluid loss of up to 4-5 litres
Loss of proteins, Na, K, Cl in the bullous fluid leads to a decreases in intravascular volume
Resultant decrease in urinary output and increase in blood nitrogen can lead to renal failure

9. Altered barrier function
Damaged skin + exudates support growth of microorganisms
Systemic infections, severe sepsis and death
Altered immunological function

10. Common dermatoses leading to acute skin failure
Exfoliative dermatitis
Bullous diseases
Pemphigus vulgaris
Bullous pemphigoid
Erythema multiforme
Toxic Epidermal Necrolysis

11. Exfoliative Dermatitis
Erythema and scaling involving a large BSA
Psoriasis – the most common antecedent illness
Miscellaneous causes include ichthyosis, pemphigus, TEN, crusted scabies, etc
Intake of drugs like sulphonamides, dapsone, antiepileptics, penicillins, etc 10 – 15% of the cases

12. Bullous Disease Immunobullous diseases like pemphigus Pemphigoid, etc
Hereditary mechanobullous disorders like epidermolysis bullosa can be life threatening

13. Pemphigus Vulgaris There are 3 main types of pemphigus
P. foliaceous (blister in the superficial granular layers
P. vulgaris ( the blisters just above the basal layer)
Paraneoplastic pemphigus that occurs in association with malignancy

14. Lesions in Pemphigus Flaccid blisters Erosions
Nikolsky’s sign is positive
Oral mucosal involvement is universal

15. Bullous Pemphigoid Subepidermal blistering skin disease of the elderly
Characterized by large, tense, bullae arising on normal or erythematous skin
Eroded skin tends to reepithelise
Drugs like penicillin, furesemide, sulfasalazine, penicicllamine, captopril, etc, local trauma, burn wounds, grafts, irritants, UV radiation and malignancies like carcinoma in stomach can precipitate this disease

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

17. Clincial Spectrum Symmetrically distributed polymorphic rash
Target lesions seen on hands with a central vesicle or erythema surrounded by a pale and then a red ring

18. TEN Extensive denudation of skin is the hallmark of TEN
Mortality rate – 40 – 50%
Malaise, pruritis, fever, prostration and myalgia are common

19. Acute Skin Failure - Management
Twin management principles
Prompt initiation of appropriate treatment
Excellent double barrier nursing care

20. Acute Skin Failure - Management
Careful observations on
Heart rate
Pulse rate
Urinary volume monitored hourly
Urinary osmolarity
Glycosuria
Temperature
Gastric contents monitored 3 – 4 hourly
Any change in extent of skin lesions and body weight

21. Acute Skin Failure - Management
Correction and maintenance of hemodynamic equilibrium by fluid and electrolyte administration
Aggressive nutritional support
Judicious use of antibiotics – to avoid strain selection, fungal infection and drug reactions
Topical antiseptics like silver sulphadiazine
Specific therapy – based on the underlying cause

22. Summarizing…
Sudden severe alterations in the anatomy and physiology of skin consequent to generalized dermatoses can lead to disabling complications
Understanding the etiopathogenesis and their prompt management in ICU on lines similar to that of burns can salvage many lives