Chapter 47: Skin Complications

Bonnie Koo; John K. Nia; Annette Czernik

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AMA Citation
Koo B, Nia JK, Czernik A. Koo B, Nia J.K., Czernik A Koo, Bonnie, et al.Skin Complications. In: Oropello JM, Pastores SM, Kvetan V. Oropello J.M., Pastores S.M., Kvetan V Eds. John M. Oropello, et al.eds. Critical Care New York, NY: McGraw-Hill; . http://accessanesthesiology.mhmedical.com/content.aspx?bookid=1944&sectionid=143518968. Accessed November 13, 2018.

MLA Citation
Koo B, Nia JK, Czernik A. Koo B, Nia J.K., Czernik A Koo, Bonnie, et al.. "Skin Complications." Critical Care Oropello JM, Pastores SM, Kvetan V. Oropello J.M., Pastores S.M., Kvetan V Eds. John M. Oropello, et al. New York, NY: McGraw-Hill, , http://accessanesthesiology.mhmedical.com/content.aspx?bookid=1944&sectionid=143518968.

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KEY POINTS

Dermatologic diagnoses are associated with longer ICU stays compared to patients with normal skin.
Any systemic infection can have cutaneous manifestations that are often nonspecific.
There are no mucosal lesions with Staphylococcal scalded skin syndrome distinguishing it from Stevens–Johnson syndrome/toxic epidermal necrolysis.
Necrotizing fasciitis is often mistaken for cellulitis. A key feature of necrotizing fasciitis is pain out of proportion to the clinical exam on initial presentation.
Meningococcemia should be considered in any patient with fever and petechial rash.
When suspecting a drug eruption a drug chart with medications and time courses is extremely helpful in identifying the causative medication.

INTRODUCTION

About 10% of ICU patients have a dermatologic diagnosis, which are associated with longer ICU stays compared to patients with normal skin.¹ This chapter will focus on skin disorders seen in the ICU setting ranging from common relatively benign disorders to life-threatening diseases. One should not hesitate to consult a hospital dermatologist to assist in the diagnosis, workup, and management of these patients.

COMMON DISORDERS

See Table 47–1; Figures 47–1 and 47–2.

Table 47–1Common dermatoses in the ICU setting.

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Table 47–1 Common dermatoses in the ICU setting.

Diagnosis	Clinical Features	Workup and Differential Diagnosis	Treatment
Contact dermatitis	Sharply demarcated, erythematous, vesicular, patch or plaque with borders corresponding to the area of contact. Chronic forms are lichenified.	Fungal, scabies, cellulitis, and eczema. No specific workup needed; rule out other conditions.	Discontinue contact with offending agent. Topical steroids (fluocinonide 0.05% ointment) to provide relief and hasten resolution.
Miliara crystallina	Small, fragile, and clear vesicles on the face and trunk appearing as “drops of water.”	Consider folliculitis. No specific workup needed; rule out other conditions.	Minimize heat and occlusion to the area.
Miliara rubra	Erythematous macules sometimes with punctate vesicles on the neck and posterior trunk or other dependent areas.	Folliculitis vs infectious such as candida. No specific workup needed; rule out other conditions.	Minimize heat and occlusion to the area. Topical steroids may be used to relieve pruritus as well as oral sedating antihistamines such as hydroxyzine.
Cutaneous candidiasis	Bright erythematous patches that are often accompanied by satellite papules and pustules and maceration often in skin folds.	Seborrheic dermatitis, contact dermatitis, and inverse psoriasis. KOH preparation or fungal culture can be done but rarely performed as lesions are typically classic.	Keep affected areas dry. Topical antifungals such nystatin powder and/or clotrimazole cream twice a day.