Introduction: Contrary to the general perception that the field of dermatology rarely encounters managing critical patients and dealing with mortality, severe and extensive dermatological conditions can be lethal in the absence of timely intervention. Aims and Objectives: The aim was to study in detail regarding the deaths and the various factors associated with it in patients admitted with dermatological conditions in a tertiary care center over a period of 10 years. Materials and Methods: It was a retrospective, record-based, observational study over a period of 10 years (2011–2021) in a tertiary care hospital consisting of 49 cases. After obtaining institutional ethical clearance, the information was obtained from medical records section. The relevant details of patients were entered in a specially formulated proforma. Results: A total of 3491 patients were admitted to the Department of Dermatology, Goa Medical College, during the study period of 10 years from January 2011 to August 2021. Among these, 49 patients succumbed to their skin condition, with an overall mortality percentage of 1.4%. Drug reactions were the most commonly encountered diagnosis in 17 patients (34.69%) which was closely followed by vesiculobullous disorders with 14 (28.57%) cases and infections in 10 (20.40%) cases. Conclusion: Drug reactions, vesiculobullous disease, and infections were the main causes of mortality in our series of patients. Extensive skin and mucosal involvement, multisystem involvement, declining age, delay in treatment received, and onset of sepsis were some of the major factors contributing to mortality. In our study, a high proportion of 46.93% of the patients were above the age of 60 years, out of which 56.52% had vesiculobullous disease. Hence, a special focus on geriatric dermatology deserves attention, especially in tertiary care centers.
Keywords: Dermatology, mortality, toxic epidermal necrolysis, vesiculobullous
| Introduction|| |
Dermatology is considered a discipline where mortality or emergencies are seldom encountered. However, severe and extensive dermatological conditions can have a lethal outcome in the absence of timely intervention.
Although disease-specific mortalities pertaining to Stevens–Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) and vesiculobullous disorders have been dealt with in the past,, there is a relative paucity of data regarding the overall mortality among inpatient dermatology patients, particularly in the Indian context.
| Materials and Methods|| |
It was a retrospective, record-based, observational study over a period of 10 years (2011–2021) in a tertiary care hospital in Goa consisting of 49 cases. After obtaining institutional ethical clearance, the information was obtained from medical records section.
The patient's demography, duration of stay, comorbidities, cause of death, hematological and biochemical parameter abnormalities, systemic involvement, presence of sepsis, assessment of disease severity by scoring disease wherever possible (TEN-Specific Severity of Illness Score [SCORTEN], Autoimmune Bullous Skin Disorder Intensity Score [ABSIS], and Psoriasis Area and Severity Index [PASI]), time lag in presentation to our institute, and prior admissions if any were noted in a preformulated proforma.
Dermatological disorders leading to death were categorized into four main categories:
- Drug reactions which included SJS, TEN, and drug hypersensitivity reactions
- Vesiculobullous disorders
- Others which included anaphylactic reactions such as angioedema, papulosquamous disorders (psoriasis), and vasculitis with extensive gastrointestinal tract involvement.
In addition, skin culture and blood cultures were recorded of all patients. No postmortems had been performed as death occurred due to known causes in the Dermatology Department.
| Results|| |
A total of 3491 patients were admitted to the department of dermatology, a tertiary care hospital, in Goa during the study period of 10 years from January 2011 to August 2021. Among these, 49 patients succumbed to their skin disorder with an overall mortality percentage of 1.4%. Females outnumbered males with 30 (61.22%) cases in the former and 19 (38.77%) cases in the latter with a female/male ratio of 1.57:1. [Figure 1] provides the distribution of deaths according to the age. The youngest patient was an 8-year-old boy, while the oldest was a 96-year-old female.
The categorization of the underlying dermatological disorder into the four groups as mentioned previously is provided in [Table 1].
The salient demographic, extent of skin and mucosal involvement, biochemical parameters, and systemic involvement in the four main groups are summarized in [Table 2].
|Table 2: Demographic, clinical, biochemical, and systemic parameters in the four groups|
Click here to view
Drug reactions were the most commonly encountered diagnosis in 17 (34.69%) cases which was closely followed by vesiculobullous disorders with 14 (28.57%) cases. Infective disorders comprised 10 (20.40%) cases, while 8 (18.62%) cases were included under “other” categories.
The most common drug reaction encountered was TEN in 7 (41.17%) cases.
On SCORTEN evaluation, seven patients had a score of 4 with mortality of 58.3%, eight patients had a score 3 with mortality of 35.3%, and two patients had a score of 2 with mortality of 12.1%. The most common drugs implicated were antibiotics (predominately cephalosporins), followed by anticonvulsants and nonsteroidal anti-inflammatory drugs (NSAIDs). Two patients (11.7%) had developed methotrexate toxicity. One patient (5.8%) each had reactions to anti-tuberculous therapy, antiretroviral therapy, and dapsone.
Vesiculobullous disorders accounted for 14 (28.57%) cases of mortality, with pemphigus vulgaris contributing to half of the mortality (50%) followed by bullous pemphigoid (28.57%).
Infections contributed to 10 (20.40%) cases with fatal outcome. Disseminated varicella (40%) and herpes zoster (40%) with systemic involvement in the form of pneumonia and meningitis and leading to multiple organ dysfunction syndrome (MODS) contributed to mortality, while 20% contribution was due to bacterial cellulitis of lower limbs.
The death that resulted due to Henoch–Schonlein purpura vasculitis was of a young 23-year-old male who succumbed due to extensive lower gastrointestinal hemorrhage in spite of improvement in cutaneous condition.
The immediate cause of death in all cases was due to cardiorespiratory arrest. The antecedent cause of death delineated in the 49 cases is depicted in [Figure 2]. Septic shock (48.9%) is the most frequently encountered cause. Blood culture reports are outlined in [Figure 3].
| Discussion|| |
A mortality percentage of 1.4% was observed in this study. However, it is much lower as compared to Nair et al. and Chowdhury et al. who had reported 3.58% and 8.4%, respectively. The lower proportion could be attributable to the fact that the rates of admission are higher in our institution. In addition, this is the only tertiary care center in the region and therefore well equipped with intensive care unit (ICU) facilities and access to necessary therapeutic modalities allowing a good standard of care.
There was an upsloping trend in mortality with increasing age, with the age group of 60–80 years reporting maximum deaths. The number of deaths in the age group of more than 60 years contributed to nearly half (46.93%) of the total deaths reported. This is similar to studies done previously.,, Old age acts as a significant risk factor as it is associated with a declining immune response and is coupled with the coexistence of comorbidities such as diabetes, hypertension, and heart diseases.
The mean age of patients who died of vesiculobullous disorders was much higher (66.67 ± 16.80 years) as compared to the other categories indicating that the older age is particularly more lethal in these cases. In addition to the risk that older age contributes to per se, we found that 28.57% were cases who were living alone and did not have a caregiver. The quality of life of these patients was gravely affected, and patients were in state of self-neglect owing to the severe skin and mucosal involvement. This highlights the paramount importance of caregivers in such chronic conditions. Geriatric dermatology is an emerging branch in dermatology, and a special attention to it, especially in tertiary centers, will help us in managing these elderly groups of critical patients where multiple factors play a role in the prognosis.
The presence of comorbidities was observed to be present in more than 60% in the categories of vesiculobullous disorders, infections, and cases such as psoriasis and systemic lupus erythematosus, while it was lower (47%) in drug reactions as most cases belonged to the younger age group. Chowdhury et al. reported 46.6% with comorbidities in their study.
The common biochemical derangements noted in all the four categories of patients were electrolyte imbalances, hypoalbuminemia (particularly in drug reactions), and deranged total leucocyte counts (especially in infections). Renal and liver function parameters were frequently compromised, details of which are provided in [Table 2].
In addition, multisystem involvement, extensive skin and mucosal involvement (more so in vesiculobullous disorders and drug reactions), MODS, and disseminated intravascular coagulation in drug reactions and infections were observed. Disease-specific mortality studies in the past have similar findings.,, However, a detailed assessment of these parameters in relation to different dermatological conditions has not been attempted so far.
Drug reactions contributed to the majority of the deaths (34.69%), especially more so in the younger age group of <45 years. The highest contribution was from TEN cases (41.17%). SJS/TEN amounted to 13.3% and 10.8% of total deaths in the studies by Chowdhury et al. and Nair et al., respectively.
In addition to the common parameters mentioned earlier, a higher SCORTEN score and a late referral of cases (42.85%) to the institution after receiving partial treatment elsewhere were contributory factors to mortality. This signifies the fact that early institution of therapy is critical in arresting further keratinocyte necrosis and plays a great role in preventing mortality.
The most commonly implicated drugs were antibiotics (cephalosporins predominately), followed by anticonvulsants and NSAIDs. In the study by Sen et al., the most common drug was carbamazepine.
Vesiculobullous disorders accounted for 28.57% of the mortality. Two other studies have indicated a mortality rate of 5%–20% for pemphigus which is similar to ours., Among the vesiculobullous disorders, pemphigus vulgaris had the highest mortality of 10% which is in tandem with the findings reported from other studies., Majority of the patients (71.42%) had a high ABSIS score at presentation.
Septicemia was the most common antecedent cause of death in our study (51%) followed by cardiorespiratory causes, which is analogous to findings by Chowdhury et al.
A majority (74%) of the cases in our study had a duration of stay in the hospital of at least 15 days (duration), while a few cases (26%) who succumbed to sudden cardiac deaths either as a part of sepsis or independently had a short stay of <7 days.
The most common organism detected was Staphylococcus aureus (9 cases) followed by Klebsiella (3 cases). In 5 cases, no organism was detected and sepsis was diagnosed on the basis of clinical presentation.
| Conclusion|| |
Skin is the largest organ of the body. Any widespread disease which threatens the integrity of this system is invariably associated with other vital organ involvement which could be fatal. Increasing age, presence of comorbidities, extensive skin and mucosal involvement, onset of sepsis with abnormal laboratory parameters, and multisystem involvement were key factors associated with mortality in our study.
Extensive severe cutaneous involvement caused by drugs, vesiculobullous disease, and infections were the main causes of mortality in our series of patients. It is prudent to have a multidisciplinary approach towards managing these critical patients with adequate facilities for intensive care.
In our study, a high proportion (46.93%) of patients were above the age of 60 years, out of which (56.52%) had vesiculobullous disease. Hence, a special focus on geriatric dermatology deserves attention, especially in tertiary care centers.
The importance of early referral of critical dermatology patients and the knowledge of potential fatality of skin conditions among primary treating physicians and public cannot be overemphasized upon!
A few limitations of our study included a small sample size, some inherent limitations of a retrospective study design, and the absence of computation of case fatality rates separately for different conditions due to the longer study period (10 years) and absence of computerized records in our hospital.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Watanabe T, Go H, Saigusa Y, Takamura N, Watanabe Y, Yamane Y, et al.
Mortality and risk factors on admission in toxic epidermal necrolysis: A cohort study of 59 patients. Allergol Int 2021;70:229-34.
Letko E, Papaliodis DN, Papaliodis GN, Daoud YJ, Ahmed AR, Foster CS. Stevens-Johnson syndrome and toxic epidermal necrolysis: A review of the literature. Ann Allergy Asthma Immunol 2005;94:419-36.
Nair PS, Moorthy PK, Yogiragan K. A study of mortality in dermatology. Indian J Dermatol Venereol Leprol 2005;71:23-5.
] [Full text]
Chowdhury S, Podder I, Saha A, Bandyopadhyay D. Inpatient mortality resulting from dermatological disorders at a tertiary care center in eastern India: A record-based observational study. Indian J Dermatol 2017;62:626-9.
] [Full text]
Sen A, Chowdhury S, Poddar I, Bandyopadhyay D. Inpatient dermatology: Characteristics of patients and admissions in a tertiary level hospital in eastern India. Indian J Dermatol 2016;61:561-4.
] [Full text]
George SM, Harrison DA, Welch CA, Nolan KM, Friedmann PS. Dermatological conditions in intensive care: A secondary analysis of the Intensive Care National Audit and Research Centre (ICNARC) Case Mix Programme database. Crit Care 2008;12 Suppl 1:S1.
Kridin K, Sagi SZ, Bergman R. Mortality and cause of death in patients with pemphigus. Acta Derm Venereol 2017;97:607-11.
Nair SP. A retrospective study of mortality of pemphigus patients in a tertiary care hospital. Indian J Dermatol Venereol Leprol 2013;79:706-9.
] [Full text]
Rosenberg FR, Sanders S, Nelson CT. Pemphigus: A 20-year review of 107 patients treated with corticosteroids. Arch Dermatol 1976;112:962-70.
Department of Dermatology, Venereology and Leprosy, Goa Medical College, Bambolim, Goa
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]