Dermatology is largely practiced in an outpatient setting with a subset of acute and severe skin disorders requiring hospitalization. Dermatological emergencies represent about 5-8% with wide variation ranging from 8–20% of the diseases seen in the Emergency Department of hospitals globally [1]. These can range from severe allergic reactions and infections to life-threatening conditions like toxic epidermal necrolysis and stevens-johnson syndrome (Table 1). Differentiating between mild and life-threatening conditions that required immediate treatment can be challenging for the duty physician[2,3] as some of these dermatoses can culminate into acute skin failure, characterized by impaired barrier function, fluid and electrolyte imbalances, thermoregulatory dysfunction, and increased susceptibility to infections.With the increase in incidence of cases of acute skin failure and true dermatological emergencies at tertiary hospitals, the need for dermatological intensive care unit is widely emphasized. The concept of establishment of an Intensive Care Unit (ICU) within dermatology setting was first introduced by Prof. Rene Touraine in 1974 [4].He advocated that patients with skin conditions progressing to acute skin failure and multiorgan involvement require specialized intensive management by dermatologist in collaboration with an intensivist [4].Dermatological entities such as drug-reactions, acute urticaria and angioedema, acute erythroderma, flare of pre-existing inflammatory dermatoses, bullous and infectious diseases demand an early diagnosis and intervention. Effective management of dermatological emergencies is often complex and time-sensitive, necessitating a multidisciplinary approach involving dermatologists, emergency physicians, intensivists, surgeons, and specialized nursing teams. Failure of which can lead to acute skin failure and multiorgan failure with significant mortality rate.

A Cross-sectional observational study of all the patients attending the adult Emergency Department (ED) of a tertiary care centre with dermatological conditions was initiated after getting approval from institutional ethics committee. The study was conducted over a period of 18 months from October 2023 to March 2025. A Detailed history of all the patients with dermatological conditions after an informed consent was taken. A thorough screening and examination of patients was done. Patients were assessed according to the onset of symptoms, distribution and examination of lesions, percentage of body surface involved and mucosal involvement – to arrive at the correct diagnosis. Systemic involvement (fever, renal dysfunction, neurological dysfunction, respiratory distress, sepsis etc.) is evaluated. Investigations are carried out to confirm the diagnosis, to rule out comorbidities and complications.The dataset comprised demographic variables, such as sex and age, as well as detailed information on diagnoses and patient outcomes.

Table 1: Common dermatological emergencies Causes Diseases Vesiculobullous disorders Pemphigus , Pemphigoid group of disorders Infections and Toxin mediated illnesses Bacterial- Staphylococcal scalded skin syndrome, Toxic shock syndrome, Cellulitis, Erysipelas, Type 1 and type 2 lepra reactions, Necrotizing fasciitis. Viral- Hemorrhagic fevers, Herpes and Varicella infections. Erythroderma Idiopathic, Psoriasis , Eczemas, Drug induced, Air Borne Contact Dermatitis, Malignancy, Seborrheic dermatitis Adverse drug reactions Steven-Johnsons Syndrome / Toxic Epidermal Necrolysis (SJS/TEN) , Drug Rash with Eosinophilia and Systemic Symptoms (DRESS) , Acute Generalised Exanthematous Pustulosis (AGEP) , Erythema multiforme - Major, Drug hypersensitivity syndrome, Maculopapular rash, Drug toxicity, Fixed drug eruption, Injection site reaction Vascular disorders Urticaria, Angioedema, Anaphylaxis, Purpura fulminans, Vasculitis (IgA vasculitis, Leukocytoclastic vasculitis) Connective Tissue Diseases Acute Systemic lupus erythematosus Physical agents Burns, Scalds Nutritional Pellagra Related to Sexually Transmitted Diseases Phimosis, Fournier’s gangrene Others Insect bite reaction, Eczema and Contact dermatitis Out of a total of 39,326 patients who attended the adult emergency department of a tertiary care hospital, 648 patients (1.64%) presented with dermatological conditions. Dermatological emergencies were most observed in the 30–50-year age group, with a sex ratio of 1.2:1 (351 males and 297 females) (Table 2). Table 2: Clinical profile of patients attending ED with dermatological conditions Dermatological conditions Frequency Percentage Acute urticaria and /or Angioedema 207 32% Infections and Toxin mediated illnesses Varicella Hemorrhagic fevers Cellulitis, Erysipelas Herpes Zoster Staphylococcal scalded skin syndrome (SSSS) Erythema nodosum leprosum Necrotizing fasciitis Purpura fulminans 120 31 25 27 17 2 13 3 2 18.5% Adverse Drug Reactions- Maculopapular rash Injection site reactions Fixed drug eruption Drug toxicity Steven-Johnsons Syndrome / Toxic Epidermal Necrolysis Erythema Multiforme (EMF) Major Drug Rash with Eosinophilia and Systemic Symptoms Acute Generalised Exanthematous Pustulosis Drug hypersensitivity syndrome (DHS) 91 32 18 11 4 9 6 5 4 2 14% Autoimmune Bullous disorders- Pemphigus vulgaris Pemphigus foliaceous Bullous pemphigoid 24 14 2 8 3.7% Erythroderma- Psoriasis Drug induced Eczema and Air Borne Contact Dermatitis Seborrheic dermatitis Malignancy 11 3 4 2 1 1 1.7% Acute Systemic lupus erythematosus 7 1.1% Cutaneous Vasculitis 21 3.2% Physical agents- Scalds Burns 18 11 7 2.8% Related to Genitalia Phimosis Fourniers gangrene 7 4 3 1.1% Insect Bite Reaction 53 8.1% Eczema and contact dermatitis 18 2.8% Pellegra 3 0.4% Others 68 10.4% Total 648 Of the 648 patients with dermatological conditions, 291 patients (45%) were treated on outpatient basis and 357(55%) patients were hospitalized, evaluated, and managed. Of the 357 patients who were hospitalized, 212 patients were admitted in DVL ward and 14 were admitted ICU, 84 were admitted in medicine ward, 18 in surgery ward,14 in plastic surgery,11 in isolation ward and 4 in urology ward after a thorough evaluation and specialist consultation. The common dermatological conditions for which patients attended ED were acute urticaria and angioedema (32%) followed by infections and toxin mediated illnesses with cutaneous manifestations (18.5%) and adverse drug reactions (14%). The most common indications for admission in DVL ward were acute urticaria and angioedema (18.5%) followed by infections and toxin mediated illnesses with cutaneous manifestations (13%), drug eruption (10%) and autoimmune bullous disorders (3.7%). Table 3: Clinical profile of patients with critical condition Dermatological condition No. of cases with critical condition Frequency No. of deceased Drug reactions- SJS/TEN Presentation Erythema Multiforme Major Drug toxicity 9 3 5 25% 8.3% 13.9% 1 0 1 Infections and toxin mediated illnesses Purpura fulminans AGEP Hemorrhagic varicella SSSS 2 1 1 2 5.5% 2.8% 2.8% 5.5% 1 1 1 1 Erythroderma Psoriasis Drug induced Air Borne Contact Dermatitis Seborrheic dermatitis Malignancy 3 4 1 1 1 8.3% 11.1% 2.8% 2.8% 2.8% 0 1 0 0 0 Bullous disorders Pemphigus vulgaris 3 8.3% 1 Total 36 8 Of the 36 true dermatological emergencies, majority were due to drug reactions (47%) followed by erythroderma(28%) and Infections and toxin mediated illnesses (16.6%). Mortality rate was higher among the patients with systemic infections and toxin mediated illnesses with cutaneous manifestations and those with acute skin failure secondary to SJS/TEN (Table 3). Most common underlying cause of death in the study is sepsis leading to multiorgan dysfunction syndrome (MODS).Mortality rate is significantly higher in males than in females.

Dermatological emergency is defined as any acute dermatological disorder that develops and worsens in less than 5 days[5].Certain dermatoses are not true emergencies but because of the acute fearing presentation many patients are seen at emergency department at any time, labelled as pseudo dermatological emergencies[6]. Patients attending emergency department with dermatological conditions range from primary cutaneous disorders to severe systemic conditions with skin manifestations. Early recognition with appropriate investigations and interventions is crucial in preventing complications and minimizing adverse outcomes[7].Majority of these dermatoses could be treated on OP basis. Out of 39326 patients who attended adult emergency department(ED) of a tertiary care hospital, 648 patients were with dermatological conditions accounting for about 1.64%, like the study conducted by Mitra et al [8] with 0.92% of total emergency department consultations. Majority of patients presenting with dermatological complaints belong to the 30–50-year age group, like study by Mitra et al [8]. Males outnumbered females with higher consultations, like study by Mitra et al [8] and Khushbu R. Modi et al [9] whereas female preponderance was seen in study by Anushka Kedia et al [10]. The most common dermatoses for which patient was treated on OP basis was acute urticaria.The most common dermatoses for which patient was admitted was acute urticaria with angioedema, similar to study by J.Y.Kim et al [11] whereas erythroderma was common dermatoses in study by samudrala et al [12] and erythema multiforme or SJS in study by Jack et al[13].True dermatological emergencies encountered in the study were acute erythroderma, severe cutaneous adverse reactions, acute vesiculobullous disorders accounting 5.5 % of total consultations at ED.SJS/TEN secondary to drugs and systemic infections with cutaneous manifestations are the common dermatoses with acute skin failure encountered at ED requiring admission in an ICU. Mortality rate was higher among the patients with systemic infections with cutaneous manifestations and acute skin failure secondary to SJS/TEN.Sepsis leading to MODS was the common underlying cause of death.Acute urticaria with angioedema is a potentially life-threatening emergency that requires rapid airway assessment and stabilization. Early involvement of an intensivist is crucial when airway compromise is suspected. Pre-emptive intubation is indicated in cases of stridor, voice changes or rapidly worsening facial or oropharyngeal swelling[14].Infections and toxin-mediated illnesses, such as necrotizing fasciitis, toxic shock syndrome, staphylococcal scalded skin syndrome, purpura fulminans, haemorrhagic varicella etc[Figure -1]. are life-threatening conditions with systemic deterioration and acute skin compromise that require urgent ICU care. Early recognition of characteristic skin findings by dermatologists is crucial for timely diagnosis and targeted specific treatment. Dermatologist play a key role in differentiating skin conditions, guiding wound care, and monitoring response. Intensivists manage systemic complications, including fluid resuscitation, infection control, airway protection, and multiorgan support. Collaborative management between dermatologist and critical care teams is essential to improve survival and reduce long-term morbidity[15]. Acute Generalized Exanthematous Pustulosis (AGEP) is a rare, self-limiting pustular eruption, most induced by medications and, less frequently by systemic infections. Distinguishing drug-induced AGEP from infection-associated pustular dermatoses is crucial, as management strategies differ. Cessation of the causative drug typically leads to resolution in the former, whereas the latter requires appropriate antimicrobial therapy. Although it is generally a benign condition, AGEP secondary to infections may be associated with significant systemic symptoms and, in rare cases, acute skin failure, requiring intensive monitoring. Early accurate, diagnosis and targeted therapy is essential to optimize clinical outcome [16] . Stevens-Johnson Syndrome (SJS), Toxic Epidermal Necrolysis (TEN), Erythema Multiforme Major (EMF), and Methotrexate toxicity are drug induced acute dermatological emergencies with significant systemic involvement. These conditions often present with extensive skin and mucosal damage [Figure 2], systemic symptoms, and risk of multiorgan failure, requiring prompt admission to intensive care units. Early identification and withdrawal of offending drug is crucial for patient survival. Dermatologists assist in diagnosis, guiding wound care, and monitoring for complications, while intensivists manage airway, hemodynamics, infections, and organ support[17]. Acute cutaneous lupus erythematosus (CLE), can serve as a clinical marker of systemic disease flare or impending organ dysfunction in patients with systemic lupus erythematosus (SLE). The sudden onset or worsening of skin lesions often parallels exacerbation of internal organ involvement, including renal, hematologic, or neuropsychiatric manifestations. Recognizing CLE not merely as a skin-limited disease but as a possible harbinger of systemic deterioration is crucial. Early dermatologic evaluation, close systemic monitoring, and timely escalation of immunosuppressive therapy can significantly alter the disease course and improve patient's outcome. Acute skin failure is the most common true dermatological emergency. Skin failure is a state in which the skin is unable to maintain its normal physiological functions such as barrier protection, thermoregulation, fluid and electrolyte balance, immune defense, and sensory perception[18]. Patients with severe compromised skin structure and function need an admission in a ICU set up due to anticipated complications such as impaired thermoregulation, fluid and electrolyte imbalance, hypovolemic shock, secondary infections and septicemia, cardiovascular failure, pulmonary oedema, disseminated intravascular coagulation. Temperature control is an important issue in acute skin failure. These patients require longer hospital stay, multidisciplinary approach as these conditions often go beyond the skin and affect multi organ systems. There is a need for awareness about true dermatological emergencies and skin failure among healthcare professionals and other medical fraternity, and is comparable to other major organ failure with high mortality. Damaged skin and its exudates support growth of endogenous and exogenous organisms potentially leading to systemic infection. Disruption of skin integrity impairs immunological function, thereby facilitating the development of severe sepsis and death. Timely initiation of appropriate treatment and excellent double barrier nursing plays a key role in the management. Hence the patients need to have a separate ICU set up with favourable environment, to decrease the duration of hospital stay, morbidity and mortality. Erythroderma, SJS/TEN, pustular psoriasis, pemphigus, and SSSS are common causes of acute skin failure, often associated with high mortality[18].Challenges faced during the study included atypical presentations and delayed healthcare-seeking behaviour, which contributed to diagnostic difficulties; difficulty in securing intravenous lines, management of pre-existing comorbidities and medical conditions, infection control and therapeutic complications. These problems were addressed with multidisciplinary approach. Currently, there is limited literature available on the spectrum of patients with dermatological conditions presenting to the emergency department. The limited existing data highlights the need for further studies to enhance early recognition and optimize multidisciplinary management of these potentially life-threatening conditions.

Dermatological conditions range from primary cutaneous disorders to severe systemic conditions with skin manifestations. Symptomatic treatment in the absence of a confirmed diagnosis is not considered appropriate in patient’s health care delivery. Timely accurate diagnosis and treatment are crucial, as delay can lead to poor outcome . A collaborative, multidisciplinary approach is essential for proper evaluation and intervention in critical condition with multisystem involvement to decrease morbidity and mortality. The study emphasizes to enhance awareness among the patients with dermatoses regarding importance of seeking timely dermatologist consultation as the skin reflects the general health condition of the individual, thereby reducing the risk of complications that could necessitate emergency or casualty care. This study highlights the need for dedicated dermatology ICUs in tertiary care settings to improve outcome of patients. Financial support and sponsorship: Nil Conflicts of interest : Nil

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