Chapter 28: Hospital-Acquired Rashes

Barbara D. Wilson

INTRODUCTION TO CHAPTER

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 exacerbates many skin problems. Many potential products that can cause allergic or irritant contact dermatitis are also found in the hospital setting including soaps, cleansers, disinfectants, topical therapies, bedclothes, adhesives, and bandages. Other factors that might contribute to hospital-acquired skin problems include the immobility of patients resulting in pressure on the skin, and nutritional impairment due to prolonged illnesses.

Finally, it is very important to remember that drug reactions are common in the hospital setting, with the number of medications that hospitalized patients receive contributing directly to this trend. Adverse drug reactions in the skin of hospitalized patients can be the result of many mechanisms. Some dermatologic reactions might be expected after exposure to a certain drug (eg, mucositis after chemotherapy) while other reactions might represent toxicity, overdose, or hypersensitivity. Hypersensitivity can be seen with many patterns. The most common by far are exanthems.⁷ Viral exanthems are not expected to be more frequently acquired in the hospital setting, but are always a challenge to differentiate from drug exanthems. In the outpatient setting, an exanthem might be more likely to be due to viral infection in the pediatric population and due to a drug reaction in the adult population, but in the hospital setting, drug reactions are more common in all settings.

APPROACH TO DIAGNOSIS

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Important factors to consider in evaluating the patient's skin problem in the hospital setting include the previous known dermatologic history, underlying systemic diagnoses, systemic medications taken over the past 3 weeks including over the counter medications, as well as the topical products that the patient has used recently. It is also important to know immediately if the patient is experiencing rapid change in their skin condition or evidence of acute skin failure. Skin pain, intense pruritus, fever, skin blisters, mucosal lesions, purpura, target lesions, or other specific signs of toxicity may indicate a serious condition.

A dermatologic problem seen in the hospital setting can certainly be that of a preexisting skin problem exacerbated by the current illness or treatment for which the hospitalization is occurring. Studies have shown that common rashes in hospitals include preexisting atopic dermatitis, seborrheic dermatitis, psoriasis, and stasis dermatitis. It is therefore important to inquire about preexisting diagnoses of skin disease and to be familiar with reasons that these diseases might flare. Examples might include a flare of atopic dermatitis due to secondary bacterial infection, a flare of seborrheic dermatitis due to inability to bathe, a flare of bullous pemphigoid due to the withdrawal of systemic steroids, or a flare of stasis dermatitis due to immobility and increased edema of the lower extremities. In the most extreme settings, the preexisting underlying dermatitis might evolve into erythroderma, defined as involvement of >90% of the body surface area.

Contact dermatitis is common in hospital settings but is rarely the cause of the hospitalization. Most contact dermatitis in the hospital is probably irritant and not allergic contact caused by exposure to strong cleansers for skin, disinfectants, and adhesives. One important opportunity for misdiagnosis due to "hidden" contact dermatitis is the "red leg." The "red leg," assumed to be cellulitis, can really be allergic contact dermatitis due to application of topical products. When diagnosing a "red leg," the physician must look for evidence of stasis dermatitis or even acute venous thrombosis as well as evidence for allergic contact dermatitis. The clinician needs to be aware of what products the patient has been using in this setting to avoid the possibility of inappropriate antibiotic use for presumed cellulitis.

Tables of Differential Diagnosis

Other common dermatologic disorders seen in the hospital as well as several high-risk problems seen less commonly are listed in Tables 28-1, 28-2, 28-3. Table 28-1 lists common inflammatory cutaneous diseases, Table 28-2 lists common infections, and Table 28-3 lists uncommon cutaneous diseases with moderate to high morbidity.

Table 28-1.Common inflammatory dermatoses in the hospital.

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Table 28-1. Common inflammatory dermatoses in the hospital.

Disease (in Textbook)

Epidemiology

History

Examination

Laboratory

Drug rash (Chapters 14 and 23)

All ages and races. Relative risk factors: female, older age, multiple medications, immunosuppression (HIV), and some concurrent viral infections. Especially common with sulfonamides, penicillins, cephalosporins, aromatic anticonvulsants, and allopurinol. Drug eruptions are overall about 10% of all hospital consults; morbilliform are most common form

Onset 4-14 days after drug initiation most common. Variable pruritus. More serious reactions such as DRESS and SJS/TEN present with high fever, skin tenderness, severe edema, extensive purpura, targets, and mucosal lesions

Morbilliform (like measles): pink, red or dull red macules, and papules with confluence especially on trunk/extremities (Figure 14-6). Dependant areas often more affected. May have polymorphous features (some areas urticarial)

Skin biopsy generally not helpful. CBC can help differentiate viral syndrome. More serious reactions may have abnormal chemistry profile and liver function tests

Urticaria (Chapter 14)

All ages, races, and both sexes. Underlying causes include URI, drug ingestions, foods, and systemic diseases including infectious, hematologic, vasculitic, and immunologic diseases. In hospital setting, drugs are the most common cause, but systemic diseases need to be considered

Abrupt appearance of transient pruritic edematous wheals. May have associated oral mucosal swelling (angioedema)

Edematous pink or red wheals of all sizes and shapes anywhere on body and transient over 24 h (Figure 14-2). May have associated angioedema (soft tissue swelling of the face) (Figure 14-3). Fever, target lesions, persistence of wheals, bruising, purpura, and toxicity indicate need to look for causes of complex urticaria⁸

Mild eosinophilia. Urticaria due to systemic disease have cytopenias, profound eosinophilia, hypocomplementemia, evidence of renal, or liver problems

Contact dermatitis (CD) (Chapter 8)

All ages, races, and both sexes. Allergic CD (eg, metals, adhesives, fragrances, preservatives, formaldehyde, and topical antibiotics) probably less common in hospital setting than irritant CD (eg, strong soaps, disinfectants, surgical preps, bedclothes, and paper products)

Irritant CD is immediate if contact irritant is strong and can have burning or pain. Cumulative irritancy with weaker irritants more commonly subacute. Allergic CD is classically delayed 1-2 days after exposure to allergen and pruritic

Well-demarcated erythematous dermatitis in areas of exposure. Irritant CD can be eczematous and scaling when subacute (Figures 8-2 and 8-3) and sometimes erosive when acute. Allergic CD can have vesicles or bullae if severe (Figure 8-5)

Skin biopsy generally not indicated. Patch tests of specific allergens can later elucidate cause if allergy is suspected

Seborrheic dermatitis (Chapter 9)

All ages, races, and both sexes; common in infants and postpubertal adults; especially common in some neurological diseases, in those on chronic steroids and HIV

Acute exacerbations of chronic dermatitis with variable pruritus. Often worse when bathing is diminished

Greasy, loose scale overlying pink dermatitis in seborrheic distribution on scalp, face, ears, intertriginous areas, chest, and upper back (Figure 9-8)

None helpful

Atopic dermatitis (Chapter 9)

All ages, races, and both sexes; atopic diathesis, family history of atopy

Chronic pruritic eczematous dermatitis with exacerbations

Infantile-extensor and face (Figure 8-7). Child and adult-flexural and possibly widespread (Figure 8-8). Poorly marginated, pink eczematous plaques often with lichenification and excoriations⁹

Possible elevated serum IgE and eosinophilia

CBC, complete blood count; DRESS, drug rash with eosinophilia and systemic symptoms; HIV, human immunodeficiency virus; IgE, immunoglobulin E; SJS/TEN, Stevens Johnson syndrome/toxic epidermal necrolysis; URI, upper respiratory infection.

Table 28-2.Common infections in the hospital.

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Table 28-2. Common infections in the hospital.

Disease (in Textbook)

Epidemiology

History

Examination

Laboratory

Viral exanthem (Chapter 27)

All ages and both sexes. More common in children. Less common than drug exanthems in hospital setting. Exposure in community and autoactivation are important factors

Abrupt onset with gradual worsening. Variable pruritus. Dependent on underlying virus but typically associated fever, cough, sore throat, myalgias, headache, lymphadenopathy, conjunctivitis, nausea, vomiting, and diarrhea

Maculopapular, morbilliform, urticarial, and vesicular lesions. Often mucosal lesions. Consider: HIV, EBV, CMV, HHV-6, HHV-7, rubella, rubeola, enteroviruses, adenoviruses, parvovirus B-19, and varicella. (All figures in Chapter 27.) Varies depending on specific causative virus

CBC with atypical lymphs, lymphopenia or lymphocytosis; LFTs, viral specific antibody tests; nasopharyngeal, throat, stool washings, and swabs

Herpes simplex (HSV)

Herpes zoster (VZV) (Chapter 11)

All ages, races, and both sexes. Worldwide. VZV more common in >age 50. Severe, recurrent HSV and VZV in immunosuppressed patients

Tingling, pain, and burning sensation may precede rash. VZV is dermatomal with possible dissemination. Rare cutaneous dissemination of HSV in atopics

Grouped vesicles and crusting on red base (Figure 11-1). HSV usually recurrent in the same place. VZV is dermatomal (Figure 11-3). Severe, widespread, ulcerating disease in immunosuppressed

Tzanck smear of lesion. DFA, PCR, and viral culture

Cellulitis (Chapter 12)

All ages, races, and both sexes. More common with trauma, portals, and broken skin

Abrupt onset of tenderness and pain with variable chills, malaise, and fever

Sudden appearance of tender, red, warm, edematous ill-defined or sharply demarcated advancing erythema, generally unilateral (Figure 12-3)¹⁰

CBC with leukocytosis and left shift. Cultures from definite portal may be helpful. Biopsy for tissue cultures if unresponsive to treatment or immunosuppressed

Pyoderma (abscess) (Chapter 12)

All ages, races, and both sexes. More common with trauma, portals, and broken skin

Acute or subacute onset of variably tender or pruritic areas of skin

Pyoderma with weeping, eroded, crusted, purulent lesions with surrounding erythema (Figure 12-1). Abscesses with tender fluctuant red nodules with or without surrounding erythema (Figure 12-2)

Skin culture after incision for abscess

Candidiasis (Chapter 10)

All ages, races, and both sexes. Risk factors: broad-spectrum antibiotics, diabetes, hyperhidrosis, occlusion, and corticosteroid use

Acute or subacute. Pruritus, tenderness, and burning

Bright red moist or erosive dermatitis, poorly marginated with satellite and lesional pustules in intertriginous areas (Figure 10-16), genitals, scrotum, and areas of occlusion (Figure 10-17). Mucous membranes with white removable exudates on red patches (Figure 38-22)

KOH with budding yeast and pseudohyphae. Cultures recommended if unresponsive to treatment

Fungal infection (Chapter 10)

All races and both sexes. T. capitis prepubertal, all other forms commonly postpubertal. M > F for T. cruris and T. pedis. Severity and extent can be worse in immunosuppressed. Relative risk factors: obesity, hyperhidrosis, age, and occlusion. Tinea is an important cause of broken skin and portals for bacterial infection (cellulitis)

Generally subacute or chronic with exacerbations

Generally dry and scaling. On body (Figure 10-4) and groin (Figure 10-7) with annular configuration and central clearing/active border. Spares scrotum. On feet, possibly moccasin (Figure 10-10) or interdigital distribution (Figure 10-9). Rarer inflammatory with vesicopustules (Figure 10-11). Nails with powdery scale and subungual debris (Figure 10-12)

KOH with branching hyphal structures. PAS stain of nail or skin will demonstrate the same. Fungal culture to identify species

CBC, complete blood count; CMV, cytomegalovirus; DFA, direct fluorescent antibody; F, female; HHV, human herpes virus; HIV, Human immunodeficiency virus; KOH, potassium hydroxide; LFTs, liver function tests; M, male; PAS, periodic acid-Schiff; PCR, polymerase chain reaction; T, tinea.

Table 28-3.Uncommon dermatoses in the hospital.

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Table 28-3. Uncommon dermatoses in the hospital.

Disease (in Textbook)

Epidemiology

History

Examination

Laboratory

Vasculitis (Chapter 25)

All ages, races, and both sexes. More common in adults with associated underlying diseases (rheumatologic, hematologic, and infectious) and also after use of certain drugs

Generally painful or burning lesions on the skin with accompanying symptoms of underlying disease

Range from nonblanching palpable purpura on the lower extremities (Figure 25-4) and dependent areas as to purpuric nodules and ulcers corresponding in size to that of the involved underlying vessel

Directed at diagnosing underlying disease and defining which organ systems may be involved. Biopsy of appropriate site can show pathologic evidence of the type of vessel involved and type of inflammation seen

Erythroderma (Chapter 9)

All ages, races, and both sexes. Most common in adults. Idiopathic type most common in adult males. Other causes: underlying severe dermatitis, Sezary syndrome, drug reaction, and pityriasis rubra pilaris

Usually acute or subacute over days or weeks. Often with preexisting milder underlying dermatologic disease (atopic, psoriatic, and seborrheic). Medications added in past weeks

Extensive pink inflamed plaques or dull erythema with and without scale covering 90% of body surface area. May have appearance of underlying skin disease

Biopsy may be diagnostic but often not in evolving disease. If chronic erythroderma, concern for hypoalbuminemia, anemia, and electrolyte disturbances. CBC and flow cytometry for cutaneous T-cell lymphoma/leukemia

DRESS syndrome (drug reaction with eosinophilia and systemic symptoms) (Chapter 14)

All ages and races. Women > men. More common in adults. More common in immunosuppressed (HIV) and also after the use of certain drugs including sulfonamides, penicillins, aromatic anticonvulsants, and allopurinol

Onset of variable exanthem along with fever and other organ dysfunction. Significant mortality especially if not recognized

Exanthem is variable. Can be morbilliform and minimal, but purpura, targets, and blisters are also described. Often extensive edema of face (Figure 14-7) and extremities and lymphadenopathy

Eosinophilia and dysfunction of other organs including kidney, liver, lung, GI tract, or other. Imperative screening for organ dysfunction if suspected

Pyoderma gangrenosum (Chapter 29)

All ages, races, and both sexes. More common in adults and those with underlying predisposing disease (inflammatory bowel disease, hematologic and rheumatologic diseases). Recent surgery or trauma to site

Rapid evolution of painful necrotic or purulent ulcer that grows quickly. Initial lesion often very painful pustule. Variable fever

Purulent, necrotic deep ulcer with undermined dusky border. Most common on lower legs (Figure 29-2), but also abdomen, peristomal, and site of surgery

Biopsy is confirmatory, but not diagnostic. Need to consider infection, vasculitis, and trauma

Erythema multiforme, Stevens–Johnson syndrome, and toxic epidermal necrolysis (see Tables 23-1, 23-2, 23-3 and Figures 23-1, 23-2, 23-3, 23-4, 23-5, 23-6, 23-7, 23-8, 23-9).¹¹

CBC, Complete blood count; GI, gastrointestinal; HIV, human immunodeficiency virus.

The online learning center at www.LangeClinicalDermatology.com has clinical self-assessment questions for this chapter.

REFERENCES

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Chapter 28: Hospital-Acquired Rashes

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INTRODUCTION TO CHAPTER

APPROACH TO DIAGNOSIS

Tables of Differential Diagnosis

REFERENCES

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