Introduction
Any organ, when it fails to perform its normal function and tasks, are considered to be organ failure. The same can be said of skin. Skin is the largest organ and has multiple functions such as it is the protective barrier against external threats, preventing entry of bacteria, and it prevents water loss and essential nutrients such as iron and protein from being lost, maintaining temperature, being responsible for the sensation, and has a role in vitamin D synthesis among other functions.
Acute skin failure is a dermatological emergency that requires immediate medical care involving a multidisciplinary approach. For the treatment to be successful, the underlying cause of the emergency should be identified and treated. Acute skin failure can occur due to various dermatological conditions. Skin failure has been defined as the loss of normal temperature, the inability to maintain core body temperature to prevent loss of body fluid and electrolytes which can result in imbalance, and the failure to prevent the penetration of external materials. Skin failure occurs as a result of multiple organ failures, such as pulmonary, cardiac, hepatic, and renal failure.
What Happens During Acute Skin Failure?
Acute skin failure follows multi-organ failure. It can be associated with
-
Hemodynamic changes.
-
Complications in metabolism.
-
Thermoregulatory impairment.
-
Electrolyte imbalance.
-
Loss of essential nutrients.
Altered Hemodynamics:
Inflammation can lead to vasodilation, which leads to increased blood flow. Clinical features include scarlet fever, redness, and edema. Erythroderma can lead to these conditions.
Increased blood flow and increased cardiac output can further increase the load on the cardiovascular system, which gives rise to cardiac failure.
Altered Thermoregulation:
The skin has the function of maintaining homeostasis. But in abnormal conditions, hypothermia or reduction in heat occurs. If the patient has extensive skin lesions, it can cause fever due to the inflammatory response. It can be seen in conditions like psoriasis. Hypothermia can be a warning sign for septic shock in some cases.
Metabolic Abnormalities:
-
Heat loss is compensated by increased metabolism, which causes a rise in basal metabolic rate (BMR).
-
Glycosuria and hyperglycemia are common in such patients, and such patients may have pancreatitis and decreased insulin secretion, infection, stress, and relative insulin resistance.
-
Impaired glucose metabolism causes caloric loss, and shivering as compensation for hypothermia is also energy-consuming.
Fluid and Electrolyte Imbalance:
-
The permeability of the skin is lost, and it causes water loss. A total loss of 400 ml/ day is usually reported. In temperate climates, the loss can be up to 600 to 1000 ml/day, and in skin failure, the loss is even more.
-
There is both transepidermal water loss and also percutaneous fluid loss by transpiration.
-
If the fluid replacement can not compensate for the loss, it can affect the intravascular volume and lead to hyperosmolar urine. This causes:
-
Decreased urine output.
-
Electrolyte imbalance, such as low sodium and high potassium.
-
Raised serum levels of urea and creatinine.
-
Insulin resistance is further aggravated by decreased phosphate levels.
-
Altered neurological status.
-
In patients with acute generalized pustular psoriasis, calcium and albumin levels are decreased.
Loss of Nutrients:
-
Protein and iron are the most commonly lost in this condition. Increased BMR (basal metabolic rate) and shedding of scales cause hypoproteinemia (reduced protein levels).
-
Exudative skin lesions cause protein loss through skin and urine.
-
Increased BMR is at the expense of protein loss. Glucose impairment further worsens the condition. These further give rise to nitrogen reduction, reduced albumin, and increased nitrogen in urine. A long-standing skin condition such as erythroderma has characteristic protein deficiency, which is evidenced by muscle wasting.
-
Iron, B12, and folate deficiency are noticed, which causes anemia.
Peripheral Edema:
Peripheral edema can be caused due to following:
-
Decreased albumin level.
-
Associated cardiac failure.
-
Inflammation due to the underlying skin condition.
Capillary leakage causes fluid to escape into extravascular spaces. This is seen in psoriasis, erythroderma, and eczema.
Pulmonary Complications:
Pulmonary edema, aspiration pneumonitis, and adult respiratory distress syndrome are all seen in skin failure. Hypovolemia (decreased cardiac output) can lead to pulmonary edema.
Altered Immune Function:
Chemotaxis, phagocytosis, and such immune functions are impaired. White blood cells, lymphocytes, neutrophils, and platelet count are affected.
Infection:
Due to reduced barrier function, the skin is prone to infections. Colonization and entry of microorganisms occur, and they can disturb gut flora. The altered immune response and increased infection can increase the chance of sepsis.
Long-term Complications:
Patients can develop deep vein thrombosis due to increased immobilization. Stress ulcers can occur as a result of sleeplessness and anxiety. Eye, skin, hair, nails, and mucous membranes can be involved.
How to Treat Patients with Acute Skin Failure?
Skin failure has to be treated as an emergency condition. It requires a multidisciplinary approach. The severity of the disease has to be assessed for the planning of the management.
There are several scoring systems that help in assessing the condition, such as PASI (psoriasis area severity index), EASI (eczema area severity index), SAPS (simplified Acute Physiological Score), SCORTEN. SCORTEN helps to predict mortality based on risk factors.
-
Monitoring hemodynamic changes.
-
Fluid loss, electrolyte imbalance, and loss of nutrients have to be addressed.
-
Hemodynamic changes must be monitored.
-
A potential complication of sepsis should be prevented.
-
Loss of water causes hypovolemia; therefore, pulse rate, urine osmolality, and urine output should be monitored. A reduction in urine output indicates hypovolemia or septicemia.
-
Pulse rate over 120/ minute or more septicemia and fever may indicate negative fluid balance.
General Management:
The patient has to be isolated and continuously monitored. Cleaning and removal of crusts should be done, along with timely dressings. Bathing one to two times per day in lukewarm water is recommended. Pulse rate, blood pressure, respiratory rate, osmolality, and urine volume should be regularly monitored.
Monitoring Hemodynamic Changes:
The loss of body fluid affects cardiac output and causes hypovolemia. In such cases, pulse rate, urine output, and urine osmolality have to be monitored. Urine output less than 50 to 100 ml/hour and osmolality less than 1020 are indicative of adequate tissue perfusion, while the reduction in urine volume is an early sign of septicemia or hypovolemia.
Fluid, Electrolyte, and Nutrition:
Skin failure has to be managed the same way as any other emergency. Fluid loss should be replaced quickly. This helps to restore body water and electrolyte balance. Slaine, human albumin, or fresh frozen plasma can be used. Human albumin is preferred more than plasma as there is a lesser chance of infection.
What Are the Prevention of Sepsis?
Proper universal precautions must be followed while treating the patient. Altered sensorium, confusion, and anxiety may be signs of sepsis. An increase in respiratory rate can be a sign of pneumonia.
What Are the Topical Management for Skin Conditions?
The skin condition should be addressed, such as oozy-denuded skin, and should be conservatively managed. Topical agents such as 0.5 percent silver nitrate, petrolatum jelly, lanolin, and permeable dressing can be used. Collagen-based dressings are also effective. Other measures include anticoagulant therapy, sedatives, and anti-anxiety medications.
Conclusion
Skin conditions can aggravate into an emergency condition due to organ failure. Loss of fluid, impairment of thermoregulation, loss of nutrients, and electrolyte imbalance are potential complications of skin failure. The skin loses its barrier function, causing infection, and the skin loses its ability to prevent fluid loss which can cause an increased metabolic rate. The condition has to be monitored and treated promptly to prevent sepsis and other fatal complications.
