severe skin flaking...anyone seen this?

meownsmile, BSN, RN · Jul 17, 2004

You say this lady had MRSA in the blood? Just a thought of mine, wondering if this lady has gotten the MRSA colonized on the skin causing almost like a cellulitis type condition without the other signs of cellulitis. Maybe it could be a combination of things causing such bad flaking. Between the cancer treatments, dehydration, probably vitamin deficencies, and the MRSA. I know MRSA can colonize in the skin, but unfortunately i havent ever seen it outside an acute care situation. The patient we have that has it colonized on the skin is usually at the point of cellulitis by the time she gets to us. I know her skin is very dry when she is at home and she uses quit a bit of cremes and lotions on her legs etc.

Audreyfay · Jul 17, 2004

I had a patient like that when I was living in Hawaii. I was working agency and did his skin care one shift. I found out 4 weeks later when I went back to that facility and he was still there. They found out he had SCABIES! Guess who also had gotten them. Almost every nurse on that entire wing! It did not look at all like classic scabies, but he had had them for so long that he had also become septic.

ktwlpn, LPN · Jul 17, 2004

I had a patient in my care yesterday who was a pretty interesting case. I had never seen anything like it (I am relatively new to nursing...still in new grad orientation). This patient had a history of skin cancer, lung cancer, and was admitted for pneumonia. The major issue all day, however, became skin care. This woman had SEVERE flaking of the skin from HEAD TO TOE. It was so terrible that the some areas were becoming raw, red, and bleeding, especially on her back. The physicians were more concerned about the pulmonary issues and sepsis (MRSA in blood) than the skin. Now, I know that dehydration can cause dry, itchy, flaky skin, but I never thought this bad. I considered dehydration to be the problem due to the following reasons: 1. patient sucked down fluids like I had never seen 2. patient stated she had had no oral intake for the previous 4 DAYS 3. patient took in 1350 cc in 8 hours and only put out 100cc very concentrated urine.
I guess my question is, has anyone ever see dehydration cause skin dryness, flaking, and itching this severe? Unfortunately, the patient was transferred to Johns Hopkins, where she had been previosuly followed, before the skin condition was addressed. I mean, this poor lady was screaming in agony, fear, and pain . Anyone seen anything like this, and if so, was it due to dehydration or is it a specific condition?

what's that syndrome-Stevens-Johnson? I have read that smaller hospitals often don't realize what they are dealing with right away and the prognosis is often poor by the time a diagnosis is made....They'll pick it up at Johns-Hopkins if that is what she had..poor thing-I have seen 2 cases of it and it is awful....

Ari RN, BSN, RN · Jul 17, 2004

Could it be Psoriasis?

luvbug9956 · Jul 17, 2004

what's that syndrome-Stevens-Johnson? I have read that smaller hospitals often don't realize what they are dealing with right away and the prognosis is often poor by the time a diagnosis is made....They'll pick it up at Johns-Hopkins if that is what she had..poor thing-I have seen 2 cases of it and it is awful....

Oh my goodness...you may be right! I know that she had told the doctors that it started right after she began a medication, which is the primary cause of SJS! But i wonder why the docs didnt pick that up. And it says here in my med dictionary that this sydnrome also has pneumonia as a presenting sign. However, this patient was elderly...it says in my book here that it happens to children and young adults...but I guess not every case is textbook. I will look this up more on the internet to see if I can find any pics of what this looks like.

Home Health Columnist / Guide · Jul 17, 2004

Sounds like Steven Johnson syndrome to me--foundation site has pics.

SJS is an immune-complex-mediated hypersensitivity disorder that may be caused by many drugs, viral infections, and malignancies. Cocaine recently has been added to the list of drugs capable of producing the syndrome. In up to half of cases, no specific etiology has been identified.

Previouly posted by Gwenith:

Here is the e-medicine entry

http://www.emedicine.com/emerg/topic555.htm

Here is the Steven-Johnson Syndrome Foundation and it lists physicians who have experience with the disease

http://www.stevensjohnsonsyndrome.net/

http://www.sadap.org.za/edl/paed/5.2.asp

Those were the best post me if you want more but basically you are right - treat like a bad bad burn.

Farkinott, RN · Jul 17, 2004

I had a patient like that when I was living in Hawaii. I was working agency and did his skin care one shift. I found out 4 weeks later when I went back to that facility and he was still there. They found out he had SCABIES! Guess who also had gotten them. Almost every nurse on that entire wing! It did not look at all like classic scabies, but he had had them for so long that he had also become septic.

I'm with Audreyfay! The last time I saw someone with anything similar to waht was described it was a humungous dose of scabies. I got it on my arm after assisiting with one transfer and I literally scrubbed my arm immediately after!

Katnip, RN · Jul 17, 2004

We had several patients on our unit with similar symptoms. Turned out they all had staph infections.

ktwlpn, LPN · Jul 18, 2004

I'm with Audreyfay! The last time I saw someone with anything similar to waht was described it was a humungous dose of scabies. I got it on my arm after assisiting with one transfer and I literally scrubbed my arm immediately after!

we have a gal with Norwegian scabies and she intially sounded like this gal-but if you've seen SJS you'll never forget it---it really is nothing like any other dermatological condition.....

luvbug9956 · Jul 18, 2004

I went to the website and looked at the pics....I dont believe this was SJS. the patient was African American though, so it might be tough to compare to these pictures, where the patients are all Caucasian. My first thought though was that the condition reminded me of a burn, which is like SJS. I guess I'll never know....

hoolahan, ASN, RN · Jul 18, 2004

I looked at the pictures too, and it didn't sound like you described, I didn't see the flaking.

I had one patient whio had something similar to what you described, but it was limited to his LE's. He swore it began after he started Coumadin. Everyone blew it off, including me, until I sat down in his home one day, with a new drug book a pharmacist gave to all of the VNA nurses who take care of his pateint's, and sure enough, it said exfoliative dermatitis was a rare side effect. I didn't know exactly what exfoliative dermatitis was, but it certainly sounded like what he had, inflammation of the skin, with exfoliation. Big flakes of skin...really gross. I thought at first he just wasn't washing well, or his CG didn't take care of him, so I insisted he get a HHA, after 2 weeks with her, I went back, and that was when I looked it up.

I called his doc in the clinic, and she was dumfounded. Coumadin is just such a common druh, we all took for granted we should focus on PT/INR's and bleeding. They couldn't stop the coumadin of course, but he did get a dermatology consult, and he got a lotion, I cant remember the name now, starts with triam... triamolone maybe?? I got the aide to help him apply it bid as rx, and in the next 2 weeks, it looked better, and soon, we didn't need to do wound care any more.

Just throwing this into the mix. When I am puzzled by weird symptoms like that, I start by making a list of all the meds the pt was on, and make a chart with all the side effects to see if it is a combo or rare one. Side effects of meds can be so bizarre.

Did this lady itch?? The pt above didn't c/o itching much, but I had another pt, w MS who had been in a SNF 2 months prior to d/c home. She suffered w itching for another 2 months, until I insisted she be examined for scabies. Finally, the doc sent his NP to the home, she did the skin scrape, and sure enough she had scabies. It wouldn't surprise me in the least if your lady spent any time in a SNF if she got it there, or even if she had a few hospitalizations. It is something that doc's don't seem to consider in a "clean" patient, and I think it goes undiagnosed more often than we likie to think about.