Skin disorders are very frequent during palliative care.
Skin is the most exposed organ of our body. Skin disorders may become major problems for patients during the terminal phase. Specific attention to skin should be paid by caregivers (particularly physicians who often spontaneously delegate this pathology to nurses), in order to avoid major pain (physical and psychological pain), a consequence of skin lesions.
Skin is a natural barrier avoiding the transmission of microbes inside the organism: clean skin and regular body care avoiding maceration are simple ways to avoid many of the general infections observed at the end of life. On the contrary, local irritation may represent the basis of any local and potentially generalised superinfection.
Skin is also the area of thermal exchange between the constant internal temperature (around 37°C) and external thermal variations. Good skin circulation enables the correction of such divergent temperature. Major skin lesions may modify these exchange possibilities (particularly near pressure points).
Skin is a very sensitive organ with several nerve terminations. Skin lesions are often very painful. These nerve terminations are most important for maintaining skin trophicity, thus explaining trophicity modifications observed during herpes or diabetes lesions.
Skin has an excellent power of regeneration (wounding and repairing), requiring a regular well furnished blood supply. Irrigation disorders (for instance through lengthy pressure in more or less conscious patients) will rapidly lead to trophic skin lesions and bedsores.
The following pages deal with:
Pruritus:
Pruritus or itching is a cutaneous sensation leading patients to regularly and severely scratch either because of a skin lesion or in the absence of any skin lesion. Scratch lesions may occur if pruritus is severe. Pruritus can be of moderate intensity and is generally and well tolerated, however it can also be intense involving considerable discomfort for the patient.
The influx conduction is relatively slow. Endogeneous pruritus is less characterised for its nervous conduction system.
Pain and pruritus do pass through the same neurological networks. At medullar level, opioids generally provoke a pruritus sensation whereas naloxone (opioid antagonist) has an anti-pruritic effect. Pruritus related to cholostasis is well controlled with anti-5HT3 treatment.
Sweating :
Sweating is a physiological function of the human skin regulating body temperature by aqueous evaporation. Except in the rare hereditary disease 'anhidrosis' (absence of development of sweat glands), infants and the sedentary elderly may have thermal regulation disorders in relation to inefficient sweating.
Regulation of sweating depends on the autonomic neurological system and is coordinated by vasodilatation (or vasoconstriction for intensely cold temperatures). Palms and soles have a basic sweat pattern which is increased by psychological stress. Other body regions (axillary, forehead) may also sweat without any increase of external temperature.
Excessive sweating or hyperhidrosis may be either localised (in neurological disorders) or generalised (pheochromocytoma, hyperthyroidism, diabetes, acromegaly, menopause, tuberculosis, lymphoma, endocarditis). Most often, sweating is related to a chronic infection which can be treated.
Discovering the cause of important sweating can help to determine efficient treatment.
Hot flushes may be a major problem for women treated for breast carcinoma with early menopause as well as for men with prostate cancer treated by hormonal therapy. Non hormonal treatment of these forms of sweating is not always efficient.
During the terminal phase, abundant sweating may appear in patients constituting major discomfort. Symptomatic treatment with cimetidine may be useful.
Skin lesions treatment :
In the terminal phase (and unfortunately sometimes far earlier), major skin lesions can be observed, either in the form of deep craters, scars or fungating tumours. These lesions are most often painful, foul smelling and exudating. They require repeated treatment which can be difficult for the caregiver to perform and may give rise to a barrier between the patient and his/her family.
The dressing should not adhere to the wound (numerous 'fat' or 'humid' dressings) but should allow high humidity to be maintained to obtain cicatrisation and should allow correct oxygenation of tissues whilst simultaneously being impermeable to bacteria.
Most often foul odours are due to necrosis and superinfection. Treatment using metronidazole gel may be indicated.
Other treatment modalities are dressings with carbon powder.
Sugar (honey and icing sugar) is another treatment for foul wounds.
You may consult the specific page on urinary and digestive fistula.
Bedsore problems :
Bedsore can be defined as an excavating wound resulting from skin hypoxia provoked by excessive prolonged pressure. Our skin needs a constant regular circulation in order to maintain its normal trophicity.
Bedsores will therefore develop at usual pressure zones when the patient lies or sits fro long periods, particularly on the buttocks and heel.
During excessive prolonged skin pressure, the progressive stages of skin lesions may be observed
Many scales have been proposed to evaluate bedsore risk: they generally consider the patient's weight (the risk is greater among slim patients), urinary or anal incontinence, general nutritional state, complete or incomplete immobilisation, possibility to move (even passively) the patient.
The most important treatment is prevention of the constitution of bedsores by:
There are two major points to consider:
Skin is the most exposed organ of our body. Skin disorders may become major problems for patients during the terminal phase. Specific attention to skin should be paid by caregivers (particularly physicians who often spontaneously delegate this pathology to nurses), in order to avoid major pain (physical and psychological pain), a consequence of skin lesions.
Skin is a natural barrier avoiding the transmission of microbes inside the organism: clean skin and regular body care avoiding maceration are simple ways to avoid many of the general infections observed at the end of life. On the contrary, local irritation may represent the basis of any local and potentially generalised superinfection.
Skin is also the area of thermal exchange between the constant internal temperature (around 37°C) and external thermal variations. Good skin circulation enables the correction of such divergent temperature. Major skin lesions may modify these exchange possibilities (particularly near pressure points).
Skin is a very sensitive organ with several nerve terminations. Skin lesions are often very painful. These nerve terminations are most important for maintaining skin trophicity, thus explaining trophicity modifications observed during herpes or diabetes lesions.
Skin has an excellent power of regeneration (wounding and repairing), requiring a regular well furnished blood supply. Irrigation disorders (for instance through lengthy pressure in more or less conscious patients) will rapidly lead to trophic skin lesions and bedsores.
The following pages deal with:
Paraneoplastic skin syndromes,
Pruritus,
Sweating,
Treatment of skin lesions,
Bedsores,
Skin tumours.
| Paraneoplastic skin syndromes: |
The most frequently observed cancer-related lesions are skin metastases (breast, permeation nodules, tumour fistula). Other skin manifestations are known as paraneoplastic syndromes:
Dermatomyositis
which can complicate many other cancer localisations,
with its typical lilac-coloured (heliotrope) erythema over the bridge of the nose, the orbital regions, cheeks, forehead, with lilac-coloured lines on the hands and fingers (particularly around the nails). The muscular syndrome is more or less severe, and more pronounced on proximal muscles. Treatment involves treating the tumour and is completed by corticosteroids.
Other paraneoplastic syndroms
Breast Paget's disease : eczema of the nipple,
Acquired ichtyosis during Hodgkin’s disease,
Acanthosis nigricans (hyperpigmentation seen on the axilla and hyperkeratosis of skin folds) during digestive cancers,
Erythema gyratum repens,
Acquired hypertrichosis lanuginosa (face hair during pulmonary and digestive cancers).
Pruritus:
Pruritus or itching is a cutaneous sensation leading patients to regularly and severely scratch either because of a skin lesion or in the absence of any skin lesion. Scratch lesions may occur if pruritus is severe. Pruritus can be of moderate intensity and is generally and well tolerated, however it can also be intense involving considerable discomfort for the patient.
Pathophysiology
Many external stimuli (physical or chemical) can provoke pruritus but also endogen stimuli (such as histamine, proteases, prostaglandins or neuropeptides). On the skin, pruritus is sensed by nociceptive unmyelinated fibres C (free endings) quite different from myelinated A fibres which transmit pain sensation.The influx conduction is relatively slow. Endogeneous pruritus is less characterised for its nervous conduction system.
Pain and pruritus do pass through the same neurological networks. At medullar level, opioids generally provoke a pruritus sensation whereas naloxone (opioid antagonist) has an anti-pruritic effect. Pruritus related to cholostasis is well controlled with anti-5HT3 treatment.
Pruritus classification
Primary pruritus
Primary pruritus is pruritus for which dermatological disease has been excluded. The main causes are:
biliary hepatic or pancreatic disease (in association with cholostasis) renal insufficiency and uraemia, various drugs (opioids, amphetamine, cocaine, aspirin, etc..),
endocrine disease (diabetes, hyperparathyroidism, thyroid disease),
haematopoietic diseases (Hodgkin's lymphoma, non Hodgkin's lymphoma, fungoid mycosis, mastocytosis, multiple myeloma, polycythaemia vera),
malignant tumours (breast, stomach, lung, carcinoid syndrom),
infectious diseases (syphilis, parasitic infection, HIV, candidiasis),
neurological disorders (distal small fibre neuropathy, tabes dorsalis, multiple sclerosis, psychosis, etc..).
In theses diseases, a liberation of mediators (such as proteases or histamine) leads to generalised and intense itching.
Secondary pruritus
Is associated with dermatological diseases
Treatment
Topical treatment
Topical treatments should be applied in case of localised pruritus or a localised region with accentuated itching. A number of preparations are active although generally for a short period of time (phenol, menthol, camphor, diphenhydramine, lidocaine, isothipendyl, local anti-inflammatory drugs).
Daily skin care is important in order to avoid scratch lesions: nails should be cut short, cool baths should be taken, soothing milky ointments should be applied, light clothes (no wool or synthetic) should be worn, including possibly humid cotton clothes which can be changed several times per day.
General medications
Among the various drugs proposed:
non-sedative antihistaminic (non anticholinergic) or sedative drug,
opioid antagonists (naloxone),
serotonin antagonists (ondansetron, granisetron),
thalidomide,
anaesthetic agents (propofol),
rifampicine is used during severe cholostasis.
Icteric pruritus (for example in pancreas cancer) is rapidly relieved by internal biliary diversion.
Sweating :
Sweating is a physiological function of the human skin regulating body temperature by aqueous evaporation. Except in the rare hereditary disease 'anhidrosis' (absence of development of sweat glands), infants and the sedentary elderly may have thermal regulation disorders in relation to inefficient sweating.
Regulation of sweating depends on the autonomic neurological system and is coordinated by vasodilatation (or vasoconstriction for intensely cold temperatures). Palms and soles have a basic sweat pattern which is increased by psychological stress. Other body regions (axillary, forehead) may also sweat without any increase of external temperature.
Excessive sweating or hyperhidrosis may be either localised (in neurological disorders) or generalised (pheochromocytoma, hyperthyroidism, diabetes, acromegaly, menopause, tuberculosis, lymphoma, endocarditis). Most often, sweating is related to a chronic infection which can be treated.
Discovering the cause of important sweating can help to determine efficient treatment.
Hot flushes may be a major problem for women treated for breast carcinoma with early menopause as well as for men with prostate cancer treated by hormonal therapy. Non hormonal treatment of these forms of sweating is not always efficient.
During the terminal phase, abundant sweating may appear in patients constituting major discomfort. Symptomatic treatment with cimetidine may be useful.
Skin lesions treatment :
In the terminal phase (and unfortunately sometimes far earlier), major skin lesions can be observed, either in the form of deep craters, scars or fungating tumours. These lesions are most often painful, foul smelling and exudating. They require repeated treatment which can be difficult for the caregiver to perform and may give rise to a barrier between the patient and his/her family.
Dressings
Dressings are the major part of treatment. They are often very painful for the patient: light sedation (for instance subcutaneous morphine) should therefore be administered before placing dressings.
The wound should first be cleansed (if necessary an infectious lesion should be treated by systemic medication) and excessive exudates should be evacuated.The dressing should not adhere to the wound (numerous 'fat' or 'humid' dressings) but should allow high humidity to be maintained to obtain cicatrisation and should allow correct oxygenation of tissues whilst simultaneously being impermeable to bacteria.
Finally, a good dressing should be as comfortable as possible.
Fighting wound foul odors
Foul odours lead to a profound feeling of dishonour and to social withdrawal. Occasionally, odours are so intense that caregivers have great difficulty in hiding their distaste. The psychological consequences for patients are immense.
Most often foul odours are due to necrosis and superinfection. Treatment using metronidazole gel may be indicated.
Other treatment modalities are dressings with carbon powder.
Sugar (honey and icing sugar) is another treatment for foul wounds.
Treating fistula
Fistula also constitutes a major embarrassment and self denigration for the patient (foul odour).
The opening of fistula and surrounding skin alteration are most often painful.You may consult the specific page on urinary and digestive fistula.
Bedsore problems :
Bedsore can be defined as an excavating wound resulting from skin hypoxia provoked by excessive prolonged pressure. Our skin needs a constant regular circulation in order to maintain its normal trophicity.
Bedsores will therefore develop at usual pressure zones when the patient lies or sits fro long periods, particularly on the buttocks and heel.
During excessive prolonged skin pressure, the progressive stages of skin lesions may be observed
 | Epidermis |
| Dermis | |
| Hypodermis | |
| Fascia and Muscle Bone with articulation. |
- Diagram of normal skin
- stage 1: erythematosous stage: redness does not disappear when pressed with the finger,
- stage 2 : phlycten stage, ie. loss of the epidermis layer with various aspects:
- serous phlycten,
- bleeding phlycten.
stage 3 : necrosis stage: necrosis covering all underlying tissues ,
stage 4 : ulcer stage: the necrosis shield disappears, profound dermis, muscle and bone are denuded.
Many scales have been proposed to evaluate bedsore risk: they generally consider the patient's weight (the risk is greater among slim patients), urinary or anal incontinence, general nutritional state, complete or incomplete immobilisation, possibility to move (even passively) the patient.
The most important treatment is prevention of the constitution of bedsores by:
Once the bedsore has formed, active treatment should be initiated:
- the use of an adapted support allowing a balanced distribution of the patient's weight,
- the use of regular movements,
- the avoidance of dangerous positions promoting skin shearing, particularly on the buttock skin.
Reading of the website recommended above shows the variety and the complexity of available treatments.
- wound cleansing,
- if necessary surgical cleansing,
- adequate dressing,
- fighting denutrition,
- fighting associated diseases like diabetes, infections or incontinence.
There are two major points to consider:
Pain is most often intense in relation to the wound and to inflammatory and infectious phenomena, and requires systematical treatment. Preventing bedsores is a major analgesic measure in palliative care. Pain may be exacerbated during dressing or when moving the patient to reduce permanent pressure. It therefore justifies preventive prescription (subcutaneous morphine).
The patient's psychological suffering is major, in relation to a degrading self-image, foul odours, movement difficulties, constant fatigue, dependence upon carers and shame before family members. The patient feels excluded by his bedsores. This shame is supplemented by the caregivers' shame in not having been able to prevent the bedsore. However, whereas most bedsores can be prevented, even the best preventive measures do not always succeed. The regular evaluation of clinical practice is necessary to ensure progress.
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