Hospitalized patients frequently have cutaneous problems that the attending physician will need to assess. These problems can range from those unrelated to the hospitalization and inconsequential at that time, to those that could be indicative of serious underlying systemic disease or even imminent life-threatening disorders of the skin. The challenge to correctly diagnose and treat a skin problem in a hospitalized patient is influenced by the lack of both access to timely dermatological consultation in some settings1 and dermatologic training received by many physicians. It is well known that referring physicians' dermatologic diagnoses and those of dermatologic consultants concur in less than half of the inpatient episodes.2–5 Implicit in this observation is the risk that many patients could then receive improper, costly, or even harmful treatments or no treatment at all. In a study of inpatient consults by Mancusi and Festa Neto in 2010, the primary doctor endorsed by questionnaire the idea that the consultation was very relevant to the hospitalization or addressed a serious dermatological problem in 31% of cases, and in another 58%, the consultation facilitated diagnosis of skin diseases that were important even if unrelated to the admitting diagnosis.3
For this reason, it is important to be familiar with both common and serious dermatoses seen in the hospital setting and to consider what unique and special risks for dermatological disease that the hospital setting might create.
The kinds of problems seen in a hospital setting and proportions of these problems are often dependent on the nature of the hospital itself (pediatric, academic, tertiary, and community) and the population that it serves as well as the specialty origin of the consultation (ie, internal medicine vs neurology).3–6 However, across many studies, there is a tendency to see certain problems frequently, including dermatitis (atopic, seborrheic, and contact), psoriasis, infectious problems (bacterial, fungal, and viral, especially candidiasis and cellulitis), and many drug reactions.1–6
The hospital setting can predispose a patient to many dermatological problems. It has been estimated in one study that approximately 36% of dermatological problems in hospitalized patients occurred after the admission.3 The hospitalized patient is especially vulnerable to infections for many reasons including exposure to prevalent and sometimes resistant hospital organisms, lowered or altered immunity due to underlying disease or treatment (eg, chemotherapy), and the loss of skin integrity caused by trauma, surgeries, and intravenous lines creating portals of entry. Searching for and discerning a portal of entry in the skin is especially important in diagnosing skin infections. In addition, some infections are caused by overgrowth, not contagion, resulting from ecologic changes (eg, candida after antibiotics), moist environments (eg, tinea in groin in bedridden patients), or by autoactivation (eg, herpes simplex virus (HSV) in immunosuppressed).
In addition to the exposure to potentially infectious agents, the hospital setting also provides a challenge to regular and careful cleansing/bathing of the skin, which ...