Many severely or terminally ill patients in natural disasters, conflict zones, and epidemics experience skin afflictions. A basic understanding of the most common and urgent skin disorders in these settings is essential to providing comprehensive care to affected patients. For example, in the days after the 2004 Asian tsunami, an Indonesian hospital reported 265 skin complaints among 235 patients seeking care.1 Similarly, a study after the 2015 Nepalese earthquake found that 52.3% of 7,326 patients had direct or indirect dermatoses following the earthquake.2
As with any conditions in crisis areas, consideration of the psychological stressors facing patients in these conditions is essential. Psychoemotional stress can aggravate many skin conditions, such as rosacea, psoriasis, eczema, acne, urticaria, seborrheic dermatitis, atopic dermatitis, and alopecia areata. It can also be linked to induction of an intense need to scratch or pick the skin (neurotic excoriation) or pull out the hair (trichotillomania).1.2
Many traumatic injuries can put the patient at risk for the development of tetanus, especially in areas where routine vaccinations are uncommon. At-risk wounds include burns, snake bites, gunshot wounds, open fractures, and any other wound with significant contamination and devitalized tissue.
Patients with tetanus-prone wounds whose immunization status is unknown should be given 250–500 units human tetanus immunoglobulin. They should also receive a dose of Td (tetanus toxoid and diphtheria toxoid) intramuscularly and complete the immunization series. This includes 3 doses (0.5 mL IM) of Td. The second dose is given in 4–8 weeks and the third is given 6–12 months after the second.
Burns can be caused by chemicals (including acids, alkali, toxic compounds, and chemical warfare agents), friction, cold, heat, and radiation damage. First-degree burns cause only superficial damage; second-degree, partial-thickness burns affect the epidermis and the dermis; and third-degree burns penetrate the dermis and affect deeper tissues. Severe, third-degree burns can result in devitalization of muscle and even bone and may require surgical intervention. In rare cases, infarction may lead to auto-amputation of affected areas.
For initial treatment for major burns extinguish the flames, which might include rolling the victim if clothing is on fire. Use large amounts of water to dilute an agent causing chemical burns, copiously irrigate affected eyes, keep any phosphorus (from chemical warfare) still in contact with victim’s skin covered with water, and supply 5–10 L/min of humidified oxygen if the airway is affected. If the patient is showing signs of shock, the legs can be elevated. If the burns occurred within an enclosed space, be watchful for signs of inhalation injury, including facial burns, hoarseness, stridor, or carbonaceous sputum. If mechanical ventilation is available, such patients should be intubated as soon as possible.
Burns should be irrigated with cool water or saline to remove loose dirt and skin then washed gently with soap and water and dried with a clean towel. Peel or trim loose, necrotic skin, but do not remove any viable-appearing skin. Drain large blisters with a sterile needle near the base of the blister, but do not remove the blister roof. Cover the burn with Vaseline gauze and change every day. Maintain mobility of the wound and avoid dependent positioning. Give oral rehydration solution and/or IV fluids. Place a clean sheet under the patient and cover with another sheet and clean blanket. Only give antibiotics if the wound is showing signs of infection. Ketamine can be used for acute pain control and during subsequent dressing changes.3,4
Snake bites result in a range of skin reactions, with simple fang marks on one extreme and marked extremity swelling, subcutaneous ecchymoses and bullae, and severe systemic symptoms, including coagulopathy and cardiovascular collapse, on the other.
Treatment involves immobilizing the bitten extremity by splinting. Keep the limb padded at heart level. Encourage the victim to drink liquids until IV access is possible. Victims may also need analgesia, transfusions, fluid resuscitation, antibiotics, steroids, and antivenom, as available.4
An open fracture is an injury that includes disruption of the skin and a broken bone. This fracture is by definition contaminated and is prone to the development of sepsis or chronic infection.
If hospital care is not immediately available, treat with a clean dressing, splint, and give broad-spectrum antibiotics. If hospital care is delayed, the wound should be irrigated with water. Angulated or malpositioned fractures should be realigned and placed in traction. Visible bone ends can be rinsed with dilute 10% povidone-iodine solution. Open fractures of the lower leg are at high risk for the development of compartment syndrome, so consultation with a surgical specialist should be sought as soon as possible.4
Treatment involves controlling hemorrhage with direct pressure. A tourniquet should only be used as a life-saving measure as it can lead to further tissue loss. Without cooling, an amputated part remains viable for 4–6 hours; with cooling, viability can be extended to 18 hours.
Cleanse the amputated part with water, wrap it in a moistened sterile gauze or towel, place it in a plastic bag, and transport on ice or snow, if available. Do not transport in direct contact with ice or ice water. Make sure the amputated part accompanies the victim throughout the evacuation process.4
This trauma differs in severity based on the type of weapon and ammunition used.
To treat firearm trauma follow basic trauma resuscitation, immobilization, wound care, and stabilization for transport. Remove the weapon from the area in which you are providing medical care. If a neck wound with an expanding hematoma is present, perform endotracheal intubation. If intubation is not possible, perform cricothyrotomy. Provide needle or chest tube decompression for a tension pneumothorax. Hemothorax should be treated with tube thoracostomy. Evacuated blood can be filtered and retransfused to the patient. Treat a sucking chest wound with Vaseline gauze secured on ¾ sides to allow egress of air from the thorax. Control external bleeding with direct pressure and compression wraps. Treat the patient for shock and hypothermia. Keep affected extremities elevated. Use forceps to remove superficial ballistic fragments. For powder burns, remove as much powder residue as possible.4
Anthrax is a zoonosis caused by Bacillus anthracis acquired from infected cattle, horses, mules, sheep, and goats. It can also be used as a biological warfare agent. The characteristic sign is a red, blistering edema. The blisters become hemorrhagic and necrotic. They eventually form black crusts and are accompanied by systemic signs.3
Treatment is with high doses of penicillin and tetracycline.
These wounds include animal or human bites to the hand, wrist, or foot, over a major joint, or through the cheek; any cat bite or scratch; deep puncture wounds; deep wounds to the hand or foot; wounds with crushed or devitalized tissue; or wounds older than 8 hours to the extremity, 12 hours to the torso, and 24 hours to the face and scalp. None of these wounds should be closed in the field.
For treatment, after irrigation and debridement, pack the wound open with saline-moistened gauze. Cover the packed wound with a conforming bandage, splint the extremity in an anatomical position and elevate it. Start broad-spectrum antibiotics, such as ampicillin-sulbactam. The wound can be closed secondarily after 4–5 days if no signs of infection develop.4
Frostbite ranges in severity based on whether tissue loss occurs. Signs and symptoms include numbness, erythema, edema, blue mottling, insensate skin with diminished pliability, blisters, mummification, and bony involvement.
Preferred field treatment is rapid rewarming (with water warmed to 40° to 42° Celsius) and prevention of refreezing after thaw. Replace constricting and wet clothing with dry, loose garments. Keep victims well hydrated, administer oxygen, elevate the injured extremity, protect them from further trauma, place gauze between the digits to prevent maceration, prohibit tobacco use, do not rupture blisters but do irrigate them, allow active motion, give analgesics including ibuprofen, and use antibiotics for extensive injury or ruptured blisters.4
Trench foot refers to prolonged exposure to nonfreezing cold and wet conditions leading to neurovascular damage without ice crystals. It starts as red skin that becomes pale and swollen. It may lead to diffuse discoloration, mottling, blistering, ulceration, paresthesias, and numbness.
To treat trench foot keep the affected area dry and warm. Initial treatment is similar to that for frostbite, but rewarming is not necessary.4
Vibro vulnificans is a flood-associated disease, most commonly acquired when an open wound is exposed to saltwater. It can cause fulminant cellulitis and myositis. Oral exposure leads to septicemia with watery diarrhea, fever, chills, nausea, vomiting, and abdominal pain. Patients with liver disease, HIV, diabetes, and other forms of immunosuppression are at highest risk.
Treatment involves supportive care and use of doxycycline and ceftazidine. It may require aggressive surgical debridement if a necrotizing soft tissue infection develops.1
Aeromonas hydrophila shares environmental attributes with the Vibrio species but is primarily found in freshwater. Humans often acquire this infection orally, and it usually presents with gastroenteritis. Immunocompromised patients are most at risk. Infection can present as cellulitis after an open wound is exposed to freshwater. Necrotizing fasciitis or myonecrosis can occur later, with severe pain, swelling, serosanguinous bullae, gas gangrene, and sepsis.
Treatment is with broad-spectrum antibiotics; surgical debridement may be required.1
Chromobacterium violaceum is commonly found on decaying organic matter in tropical and subtropical freshwater and soil. Skin disease usually results from minor skin breaks being exposed to contaminated water. Cutaneous manifestations include cellulitis with pustules and nodules or ecthyma gangrenosum-like lesions after dissemination. Initial infection can rapidly progress to fulminant sepsis with multiorgan involvement. Visceral abscesses can rapidly develop.
Treatment involves surgical drainage of cutaneous and visceral abscesses, along with several weeks of broad-spectrum IV antibiotics.1
Mucormycosis is a fungus that is particularly dangerous in immunocompromised hosts. Skin infections occur after traumatic injury to the skin and exposure to the environment. Cutaneous disease usually presents as refractory infection of a simple abrasion or traumatic wound. If untreated, Mucor infection can progress to severe, extensive tissue necrosis, gangrene, and severe or fatal systemic infection.
Treatment is with aggressive surgical debridement, systemic antifungals, particularly amphotericin B.1
General Skin Care
This is a symptom in many skin disorders. In refractory pruritus, the patient’s skin can become thickened and form a dry, raised plaque with a darkened skin color known as lichenification. Some parasitic infections, such as schistosomiasis, may cause intermittent, itchy wheals or urticaria. If additional members of the household are also itching, and the patient has itchy bumps on the genitals, finger webs, and other areas, scabies should be considered. Other causes of pruritus include iron deficiency, renal failure, thyroid disease, liver disease, lymphoproliferative diseases, drug reactions, and psychological disorders.
Treatment is based on the underlying cause. If no cause can be found, symptomatic relief can be attempted with topical steroids, antihistamines, emulsifying ointments, menthol cream, oatmeal soaks, gabapentin, and amitriptyline, as appropriate.5,6,7
Edema is usually caused by the accumulation of fluid in the tissue. The swelling is initially soft but can harden with time from fibrosis or scarring. Edema can also become secondarily infected with bacteria and appear weepy and bumpy. If area is warm and tender, this may suggest an infection.
Filariasis can cause pronounced extremity and genitourinary swelling, with a foul-smelling discharge.
Mycetoma causes unilateral, painless, and localized swelling, often to the feet, with draining sinus tracts.
These are mycobacterial infections that cause an indolent, painless ulcer with undermined edges. Before a Buruli ulceration occurs on a limb, the skin surface is usually swollen or may blister. Once a Buruli ulcer forms, there is usually pronounced swelling around the ulcer.
Kaposi’s sarcoma (KS) often causes edema, with overlying purple, red or dark-colored patches, papules, or nodules. Patients often also have lymphadenopathy in the affected limb, and the swelling tends to be asymmetrical.
Heart, Liver, and Kidney
Heart, liver, and kidney failure may cause bilateral leg swelling but is usually relatively symmetrical and accompanied by other systemic symptoms.
Treatment will target the underlying cause. In general, treatment involves massage for lymphedema, compression with elastic bandages and leg elevation, moisturizers to prevent skin breakdown, leg movement through walking or passive movements, and support stockings. Topical steroids and diuretics can be used to improve skin symptoms from noninfectious causes of leg edema. Antibiotics can be used for superimposed infection, along with targeted antiparasitics and antifungals (depending on the cause), and antiretrovirals and/or chemotherapy for KS. 5,7,8
These tumors frequently cause pain, odor, excessive drainage, and bleeding, which can lead to social isolation and significant distress. It is not unusual to see maggots in the wound if care has not been optimized.
Treatment (for palliation) is as follows:
Pain: Premedicate before dressing. Soak any dressings that are adhered to the tissue to prevent bleeding and pain. Rinse with normal saline or rock salt (2 teaspoons or 10 g) boiled into 1 L warm water.
Odor: Remove loose debris with rinsing. Crush metronidazole tablets into powder and apply to the wound by shaking or throwing the powder onto the wound. Careful debridement of thick, necrotic, loose tissue can be attempted for severe odor. Cover entire tumor with Vaseline gauze or similar non-stick dressing to trap odors. This can also help with hemostasis and clear up anaerobic infection. Metronidazole tablets can also be inserted in a sinus or orifice. This is useful for rectal and cervical cancer.
Drainage: For excessive drainage, use disposable baby diapers to soak up drainage and protect clothing. Secure in place using wide gauze wraps.
Bleeding: Try to minimize bleeding by preventing dressing from sticking to the tumor. For mild to moderate bleeding, apply pressure for 10–15 minutes. For persistent or severe bleeding, consider Tranexamic acid 650 mg (crushed) or 1 g injectable in 5–10 mL saline applied to gauze tid. One can also try 1:1000 adrenaline-soaked gauze or sucralfate 1–2 g/10 mL suspension bid applied to the wound. For terminal hemorrhage, it is best to use dark towels and have a plan in place for sedation and pain relief.
Maggot removal: Use hydrogen peroxide to rinse the wound and pick off the maggots as they come to the surface.
Chronic Skin Conditions
Conditions such as eczema, psoriasis, and bullous pemphigoid can all flare during intensely stressful situations.
Even if patients in crisis areas do not have access to their regular medications for these chronic conditions, symptomatic relief can often be achieved with oral steroids. Ensure that an adequate supply is given to the patient so they can either taper the steroids or continue their current dose.
Superimposed Bacterial Infections
Such infections may occur on damaged skin. Common bacteria causing them include Streptococcus, Staphylococcus, and Pseudomonas. Injured skin is more susceptible to bacterial infection, which can present as cellulitis, boils, pustules, furuncles, and necrotizing fasciitis.
Treatment is with broad-spectrum penicillins, surgical debridement as needed, and daily dressings. If you are in an area with a high prevalence of methicillin-resistant Staphylococcus aureus (MRSA), treatment regimens may need to be modified. Dilute vinegar and bleach (diluted to barely smell like a swimming pool) washings can also be used. Necrotizing soft tissue infections requires urgent surgical debridement.
Malnutrition can cause a variety of skin manifestations and may require specialized intervention. For isolated vitamin deficiencies, the vitamin in question can be targeted for supplement treatment. The key is to recognize signs of each deficiency by physical examination.
Kwashiorkor causes bilateral, pitting limb edema, periorbital edema, desquamation, hair changes, lethargy, and hepatomegaly.
Beriberi (Vitamin B1 Deficiency)
Deficiency in vitamin B1 causes neuropathy, limb weakness in dry beriberi, and pronounced swelling in wet beriberi.
Pellagra (Vitamin B3 Deficiency)
This deficiency causes a classic triad of dermatitis, diarrhea, and dementia. The dermatitis is a photosensitive, sunburn-like rash at sun-exposed sites. There can also be a collar-like ring of scaly skin around the neck known as Casal’s necklace. Lesions are sensitive and inflamed, and later they can become scaly and peel off. There are atrophic patches between the fingers, and nails become brittle and atrophic.
Vitamin B12 deficiency
This deficiency can cause hyperpigmentation of the hands and feet, angular stomatitis, as well as blood dyscrasias and neurological abnormalities.
Scurvy (Vitamin C Deficiency)
Scurvy is characterized by swollen, painful joints, dry skin, hyperkeratosis of hair follicles, “corkscrew hairs,” bruising, petechial hemorrhage, and dental caries.
Deficiency in zinc can cause scaly lesions on the feet, buttocks, and around the mouth, stunting, developmental delay, recurrent infections, failure to thrive, and persistent diarrhea.8
Noninfectious Skin Diseases
Lupus erythematosus (LE) occurs mainly in three forms—systemic (acute, visceral), subacute cutaneous (SCLE), and discoid, mainly involving the skin in sun-exposed areas (chronic, cutaneous). Features of lupus include redness of the skin, telangiectasia, hyperpigmentation and hypopigmentation, follicular hyperkeratosis, and atrophy. Several drugs may cause lupus-like symptoms or trigger systemic LE (such as procainamide, isoniazid, hydralazine, and anticonvulsants). In lupus-like drug reactions, symptoms resolve a few weeks after stopping the drug. Patients with LE are often photosensitive, hence the facial butterfly patch rash where the skin is exposed to the sun.
Therapy involves UV barrier protection, oral and topical steroids, immunosuppressants, and hydroxychloroquine.5
Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis
Stevens-Johnson syndrome is a systemic disorder with pronounced blistering affecting the oral and genital mucous membranes and the skin. The outcome may be fatal because of dehydration and superimposed sepsis. Serious complications can include corneal ulceration, uveitis, and panophthalmia. Other complications include scarring and adhesions, particularly on the eyelid (synechia). Stevens-Johnson syndrome/toxic epidermal necrolysis is most often caused by a drug reaction, commonly penicillins, sulfa drugs, and HIV medications.
Treatment is with IV fluids to prevent dehydration, Vaseline gauze, removal of offending agents, and pain medications including sedation for severe forms. Daily dressing changes and daily clean sheets are also required.5
Crusted scabies is a diffuse, crusted form of the pruritic scabies mite infection. Scabies is transmitted by direct human-to-human contact and is common in overcrowded conditions. This form of scabies can be found in HIV patients, as well as among elderly and immunocompromised persons. Itching is intense and often worsens at night. Patients shows signs of scratching along with the characteristic scabies burrows and widespread intense, erythematous lichenification, sometimes containing pus. The face is usually spared and the genitals are invariably involved. Other sites commonly involved include the hands, finger webs, nipples, axillae, and inguinal folds.
Treatment requires decontamination of clothing and bedding and several applications of benzyl benzoate or permethrin to the whole skin surface except the head. Oral ivermectin is very effective and be necessary in the crusted variant. Symptomatic relief can be given with topical and systemic antipruritics. 7,9
Zoster is caused by infection with varicella-zoster virus, which causes chickenpox and may subsequently remain dormant in nerve ganglia. With waning immunity or at times of stress or old age, the virus can reactivate, resulting in herpes zoster eruption along the dermatomal distribution of the nerve root. The initial symptom is usually pain with or without burning and/or itching in the nerve-root distribution for up to a week before the lesions erupt. This pain can be severe. Lesions appear as grouped vesicles on an erythematous base. In immunocompromised patients, the eruption can be generalized and highly debilitating.
Treatment involves analgesia, including gabapentin and amitriptyline, povidone-iodine, systemic antiviral agents, oral steroids (only with antivirals for complications), and urgent ophthalmology consult for eye involvement. Pregnant patients and those who have not had chicken pox or been vaccinated for varicella should be kept away from infected individuals or wear protective covering.5
Syphilis is a sexually transmitted infection. It has three stages. The primary stage is a painless (usually genital) ulcer. The secondary stage is marked by generalized symptoms of variable severity, such as headache, hoarseness, sore throat, fever, and muscular aching. The rash in the secondary stage consists of raised pink to brown papules and plaques of variable scale. Characteristics of this rash are relatively abrupt onset with involvement of the palms and soles. Hair loss is frequent. The tertiary stage is rare and involves the heart, nervous system, and skin. Skin lesions tend to be annular, with a healing scarred center and slowly advancing outside edge.
Treatment is with penicillin; all exposed partners should be treated. Add probenecid for tertiary-stage syphilis and for patients with AIDS. Use doxycycline for penicillin-allergic patients.5
Cutaneous Tuberculosis (TB)
The cutaneous primary complex consists of a tuberculous chancre, lymphangitis, and lymphadenitis. The primary lesion starts as a soft papule, which quickly disintegrates. Lupus vulgaris (cutaneous facial TB) often presents as a destructive, central-facial, verrucous plaque with nasal destruction.
Treatment involves multidrug, prolonged treatment.5.9
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