Chapter 27: Hospital Acquired Rashes

INTRODUCTION TO CHAPTER

Hospitalized patients frequently have cutaneous problems that the attending physician will need to assess. Skin disorders occur in as many as one third of all inpatients.^1,2 These problems range from those unrelated to the hospitalization and inconsequential at that time, to those that could indicate life threatening disorders of the skin or serious underlying systemic disease. The challenges to correctly diagnosing and treating a skin problem in a hospitalized patient is influenced by both access to timely dermatological consultation and the lack of adequate dermatologic training received by many non-dermatologist physicians or advanced care providers.³ It is well known that referring physicians' dermatologic diagnoses and those of dermatologic consultants concur in less than half of inpatient episodes.^4–8 Implicit in this observation is the risk that many patients could receive improper, costly or even harmful treatments or no treatment at all. Improper or delayed diagnoses and treatment can lead to prolonged hospitalizations and higher readmission rates.^8,9 Some papers now address ways for inpatient dermatology to be more available by including the utilization of teledermatology.^10–12

For the non-dermatologist attending, it is important to be familiar with both common and serious dermatoses seen in the hospital setting and how the hospital setting might contribute to these.

The type and scope of problems seen in a hospital setting are often dependent on the nature of the hospital itself (pediatric, academic, tertiary, community) and the population that it serves as well as the specialty origin of the consultation (i.e., internal medicine vs. neurology). Certain problems are seen frequently, including dermatitis (atopic, seborrheic, contact), psoriasis, infectious problems (bacterial, fungal and viral, and especially candidiasis and cellulitis), and drug reactions.^1,5,7,12,13

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.⁶ 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 (e.g., chemotherapy),¹⁴ 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 (e.g., candida after antibiotics), moist environments (e.g., tinea in groin in bedridden patients) or by autoactivation (e.g., herpes simplex virus (HSV) in immunosuppressed individuals).

In addition to exposure to potentially infectious agents, the hospital setting also provides a challenge for regular and careful cleansing/bathing of the skin which can exacerbate many skin problems. Also, many potential products that can cause allergic or irritant contact dermatitis are also found in the hospital setting ...