Dermatological manifestations in the intensive care unit – A prospective study

Intensive care unit (ICU) is a specialized unit to manage critically ill patients. As the patient is already on life support, on multiple medications and immobile, it creates an environment for growth of organisms which can lead to a variety of nosocomial infections including cutaneous infections [1,2]. Moreover, as the mobility of the patient is impaired, the chances of complications like decubitus ulcers are increased manifold. Various dermatological problems may develop in ICU patients as a result of primary pathologies, their complications, and complex treatment regimens used for therapy. Dermatological conditions can increase the risk of complications, increase in the stay duration, can lead to alteration in the treatment regimens and can also increase the morbidity and mortality [3,4].


INTRODUCTION
Intensive care unit (ICU) is a specialized unit to manage critically ill patients.As the patient is already on life support, on multiple medications and immobile, it creates an environment for growth of organisms which can lead to a variety of nosocomial infections including cutaneous infections [1,2].Moreover, as the mobility of the patient is impaired, the chances of complications like decubitus ulcers are increased manifold.Various dermatological problems may develop in ICU patients as a result of primary pathologies, their complications, and complex treatment regimens used for therapy.Dermatological conditions can increase the risk of complications, increase in the stay duration, can lead to alteration in the treatment regimens and can also increase the morbidity and mortality [3,4].
We undertook this study to study the dermatological manifestations in the patients admitted in the intensive care unit.

DISCUSSION
In an intensive care unit, prolonged immobilization, malnutrition, impaired tissue perfusion, immune system dysfunction, fluctuations in body temperature, inadequate hygiene, hyperpyrexia, medications, and skin injuries may cause the disruption of the skin barrier function, which predispose the patients to a large number of dermatological disorders ranging from infections to non infectious dermatoses like drug reactions and frictional blisters [1][2][3][4].The incidence of dermatological disorders in patients in ICU has been reported to vary from 2.2% to 21.5% [3,5].In agreement with the literature, our study demonstrated an incidence of 18.31%.Skin infections constitute the major dermatological manifestations in the ICU.Fischer et al reported an incidence of 29% of different skin infections whereas Emre et al reported an incidence of 38.9% [2,5].Among the infections, fungal infections are the most common infections with Candida being the most commonly implicated pathogen, which is attributed to increased humidity, administration of broad spectrum antibiotics, parenteral nutrition, immunosuppressive agents, and comorbidities [2,6].In our study, the incidence of infective skin disorders was 52%, among which fungal infections were the most common with dermatophytoses constituting 14% of the total infection load, followed by Candidiasis in 12%.The low incidence of bacterial infections could be attributed to the co administration of antibiotics to the patients.Drug reactions constitute another major dermatological manifestation in the ICU with various studies reporting an incidence varying from 9.3% to 21.6% [2][3][4][5]7].Emre et al reported that drug reactions occurred in 14.5% of patients staying at intensive care units with maculopapular rash being the most common subtype [2].Antibiotics and chemotherapeutic agents are the most common drugs implicated in causing drug reactions.Anticonvulsive agents, allopurinol, diuretics, and non-steroidal antiinflammatory drugs may also cause drug reactions [7].In our study, drug reactions constituted 24% of all dermatological manifestations and maculopapular drug reactions were the most common type.
Apart from the drug reactions, other non infectious dermatoses like friction blisters, vasculitis, seborrheic dermatitis are also very common in patients in ICU.Emre et al reported that dermatoses are observed at intensive care units at a rate of 46.6%, and the most common pathologies were frictional bullae and allergic contact dermatitis, whereas, Fischer et al, reported an incidence of 49.4% [2,5].Another study reported that the most common skin disorders were stasis dermatitis (25%) and diaper dermatitis (25%) in medically treated critically ill patients [8].In our study, apart from drug reactions, the most common dermatoses were friction blisters (12%, n=6) and dermatitis (4%, n=2).Urticaria, psoriasis and vasculitis were seen in one patient each.Immobilization, numerous medications, higher age increase the fragility of skin, therefore when frequent friction is applied, it leads to friction blisters.Moreover, continuous use of topical irritant agents like electrodes, chlorhexidine also predispose to the development of eczemas in the already fragile skin [9,10].
Skin diseases can markedly prolong the stay in ICU.Many factors including age, multiple comorbid conditions, duration of ICU stay, time to consultation, and mortality contribute to the development of dermatological disorders.Increased cooperation is needed among ICU physicians and dermatology department to reduce the dermatological complications, increase the quality of patient care, shorten hospital stay, and reduce mortality rate.