Hospitalized patients frequently have cutaneous problems that the attending physician will need to assess. These problems can range from those unrelated to the hospitalization and inconsequential at that time, to those that could be indicative of serious underlying systemic disease or even imminent life-threatening disorders of the skin. The challenge to correctly diagnose and treat a skin problem in a hospitalized patient is influenced by the lack of both access to timely dermatological consultation in some settings¹ and dermatologic training received by many physicians. It is well known that referring physicians’ dermatologic diagnoses and those of dermatologic consultants concur in less than half of the inpatient episodes.^2–5 Implicit in this observation is the risk that many patients could then receive improper, costly, or even harmful treatments or no treatment at all. In a study of inpatient consults by Mancusi and Festa Neto in 2010, the primary doctor endorsed by questionnaire the idea that the consultation was very relevant to the hospitalization or addressed a serious dermatological problem in 31% of cases, and in another 58%, the consultation facilitated diagnosis of skin diseases that were important even if unrelated to the admitting diagnosis.³

For this reason, it is important to be familiar with both common and serious dermatoses seen in the hospital setting and to consider what unique and special risks for dermatological disease that the hospital setting might create.

The kinds of problems seen in a hospital setting and proportions of these problems are often dependent on the nature of the hospital itself (pediatric, academic, tertiary, and community) and the population that it serves as well as the specialty origin of the consultation (ie, internal medicine vs neurology).^3–6 However, across many studies, there is a tendency to see certain problems frequently, including dermatitis (atopic, seborrheic, and contact), psoriasis, infectious problems (bacterial, fungal, and viral, especially candidiasis and cellulitis), and many drug reactions.^1–6

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.³ 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 (eg, chemotherapy), 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 (eg, candida after antibiotics), moist environments (eg, tinea in groin in bedridden patients), or by autoactivation (eg, herpes simplex virus (HSV) in immunosuppressed).

In addition to the exposure to potentially infectious agents, the hospital setting also provides a challenge to regular and careful cleansing/bathing of the skin, which exacerbates many skin problems. Many potential products that can cause allergic or irritant contact dermatitis are also found in the hospital setting including soaps, cleansers, disinfectants, topical therapies, bedclothes, adhesives, and bandages. Other factors that might contribute to hospital-acquired skin problems include the immobility of patients resulting in pressure on the skin, and nutritional impairment due to prolonged illnesses.

Finally, it is very important to remember that drug reactions are common in the hospital setting, with the number of medications that hospitalized patients receive contributing directly to this trend. Adverse drug reactions in the skin of hospitalized patients can be the result of many mechanisms. Some dermatologic reactions might be expected after exposure to a certain drug (eg, mucositis after chemotherapy) while other reactions might represent toxicity, overdose, or hypersensitivity. Hypersensitivity can be seen with many patterns. The most common by far are exanthems.⁷ Viral exanthems are not expected to be more frequently acquired in the hospital setting, but are always a challenge to differentiate from drug exanthems. In the outpatient setting, an exanthem might be more likely to be due to viral infection in the pediatric population and due to a drug reaction in the adult population, but in the hospital setting, drug reactions are more common in all settings.

Important factors to consider in evaluating the patient’s skin problem in the hospital setting include the previous known dermatologic history, underlying systemic diagnoses, systemic medications taken over the past 3 weeks including over the counter medications, as well as the topical products that the patient has used recently. It is also important to know immediately if the patient is experiencing rapid change in their skin condition or evidence of acute skin failure. Skin pain, intense pruritus, fever, skin blisters, mucosal lesions, purpura, target lesions, or other specific signs of toxicity may indicate a serious condition.

A dermatologic problem seen in the hospital setting can certainly be that of a preexisting skin problem exacerbated by the current illness or treatment for which the hospitalization is occurring. Studies have shown that common rashes in hospitals include preexisting atopic dermatitis, seborrheic dermatitis, psoriasis, and stasis dermatitis. It is therefore important to inquire about preexisting diagnoses of skin disease and to be familiar with reasons that these diseases might flare. Examples might include a flare of atopic dermatitis due to secondary bacterial infection, a flare of seborrheic dermatitis due to inability to bathe, a flare of bullous pemphigoid due to the withdrawal of systemic steroids, or a flare of stasis dermatitis due to immobility and increased edema of the lower extremities. In the most extreme settings, the preexisting underlying dermatitis might evolve into erythroderma, defined as involvement of >90% of the body surface area.

Contact dermatitis is common in hospital settings but is rarely the cause of the hospitalization. Most contact dermatitis in the hospital is probably irritant and not allergic contact caused by exposure to strong cleansers for skin, disinfectants, and adhesives. One important opportunity for misdiagnosis due to “hidden” contact dermatitis is the “red leg.” The “red leg,” assumed to be cellulitis, can really be allergic contact dermatitis due to application of topical products. When diagnosing a “red leg,” the physician must look for evidence of stasis dermatitis or even acute venous thrombosis as well as evidence for allergic contact dermatitis. The clinician needs to be aware of what products the patient has been using in this setting to avoid the possibility of inappropriate antibiotic use for presumed cellulitis.