Dermatological Emergencies in the Intensive Care Unit: Necrotizing Skin and Soft Tissue Infections and Severe Cutaneous Adverse Reactions

Abstract

Dermatological emergencies are a rare cause of intensive care unit admission but are associated with a high mortality rate and a high risk of long-term sequelae for survivors. They predominantly consist of necrotizing soft tissue infections (NSTI) and severe cutaneous adverse reactions (SCARs), including toxic epidermal necrolysis (TEN), Stevens-Johnson syndrome (SJS) and the drug reaction with symptoms (DRESS) syndrome. These diseases are often difficult to diagnose and require a pluridisciplinary approach together with heavy and specific nurse care, frequently leading to transfer to expert centers. NSTI management during the early phase combines a surgical debridement of all infected tissues and the prompt initiation of a broad-spectrum empiric antibiotherapy. Presence of severity signs whether local (necrosis, crepitations, intense pain) or general (sepsis/septic shock) should prompt urgent surgical exploration. It’s readiness is the main modifiable prognostic factor, guidelines on adjunctive therapies (intravenous immunoglobulins, hyperbaric oxygen, negative pressure wound dressings, ...) being to date based on weak evidence. The key initial step of SCARs management is the identification and removal of all culprit drugs. TEN management is mainly supportive and includes the correction of dehydration and associated metabolic disorders, hypothermia prevention, prevention and treatment of infections, analgesia, anxiolysis and skin care. Infectious and respiratory complications are the main cause of death during the acute phase. No specific treatment has proven its efficacy. The diagnosis of DRESS syndrome may be difficult and its management should involve a multidisciplinary team, depending on the clinical presentation. Severity is related to possible organ involvement (cardiac, hepatic, and renal). Treatment of the most severe forms relies on immunosuppression (systemic corticosteroids).