Other factors affecting skin breakdown

Malignancy can affect the skin barrier when the pathological process leads to a breakdown in skin integrity, such as a malignant fungating wound, which may include mycosis fungoides, a type of cutaneous T-cell lymphoma. Whilst such problems will require wound care, the effects of cancer treatments can have implications for skin care. Iatrogenic effects or the effects of medical treatment on the skin such as radiotherapy effects and adverse drug reactions (ADRs) are now examined.

Radiotherapy
Radiotherapy may cause acute radiation dermatitis, with the reaction intensity depending on the dose, the treated area and individual variation (Tucker et al., 1984). Common effects on the skin include erythema, which resembles severe sunburn, and peeling or desquamation; rarely it can lead to necrosis (Porock and KristJanson, 1999). Skin reactions tend to be short lived; they are also uncomfortable for patients, with accompanying itch and pain at times (Campbell and Illingworth, 1992).

Adverse drug reactions
Adverse drug reactions (ADRs) or side effects can have a significant cutaneous effect, which may lead to a significant breakdown of skin integrity. They can account for 5% of all hospital admissions in the UK and between 10% and 20% of hospital inpatients (The National Prescribing Centre, 1998) and hence can be a common reason for dermatological contact with other hospital areas. Whilst a rash is a common skin reaction, drug eruptions can be severe and lead to skin barrier breakdown (see Less common skin conditions for more details on drug reactions).

The mechanisms of ADRs include anaphylactic reactions (type I), cytotoxic reactions (type II) and immune complex–mediated reactions (type III), in which combinations of some of these mechanisms may occur (Mackie, 2003). Typical cutaneous reaction patterns due to ADRs are summarised in Table 4.1.

Table 4.1 Cutaneous reaction patterns due to ADRs.   Reaction pattern Likely drugs   Toxic erythema Antibiotics, sulphonamides, barbiturates, anti-rheumatics   Erythema multiforme and Stevens–Johnson syndrome Antibiotics, sulphonamides and anti-rheumatics   Erythema nodosum Contraceptive pill, sulphonamides   Erythroderma Antibiotics and anti-rheumatics   Vasculitis and purpuric eruptions or aggravation of psoriasis Phenytoin, indomethacin   Very severe blistering eruption (toxic epidermal necrolysis) Sulphonamides, allopurinol and phenylbutazone   Photosensitivity Tetracyclines, phenothiazines   Acne Phenytoin   SLE-like syndrome Hydralazine, penicillin and sulphonamides   Exfoliative dermatitis Gold, isoniazid and phenylbutazone     Source: Based on Mackie (2003).

In countries such as South Africa, which have high HIV-AIDS prevalence and so a highly immuno-compromised population, some conditions such as severe blistering condition toxic epidermal necrolysis are much more common, which has a significant effect on skin breakdown and perhaps a major challenge for nursing and medical care. Strong (1998) gives further details on dermatological emergencies from a nursing perspective.