Palliative Dermatology

INTRODUCTION

Palliative care is aimed at reducing the physical, mental, social, and spiritual pain of the critically ill patients irrespective of the diagnosis.[1] Going with this definition, dermatologists who have minimal chance to encounter emergencies and pain may be the one playing the least important role in a multidisciplinary team of palliative care. However, as the knowledge about the close interconnection between dermatology and psychiatry is built up recently, the above-mentioned notion about the role of the dermatologist in palliative care is gradually changing.

SKIN AND MIND

There is an unquestionable bond between skin and mind (or brain). Developmentally, both have the ectodermal origin. Recent studies have included skin as an integral part of Neuro-Immuno-Cutaneous-Endocrine system, which clearly plays a role in stress-related changes in human organ systems. Newer concepts such as neurogenic inflammation, where the stress-induced products of cutaneous sensory nerve endings trigger and induce the cutaneous inflammatory response, further illustrate the interconnection between the skin and neural system.[2]

PALLIATIVE PSYCHODERMATOLOGY

It has been reported that in hospice services 50% of the patients will experience symptoms of depression, 70% will experience clinically significant anxiety, and nearly all patients will experience delirium as they near death.[3] In this context, dermatoses such as psoriasis, with an established relationship with psychological factors, can appear de novo or the preexisting diseases can be aggravated. In our experience, reverse situation also prevails among palliative patients that skin disorders irrespective of the diagnoses cause significant anxiety of disfigurement and social inhibitions.

RISK FACTORS OF DERMATOSES IN PALLIATIVE CARE PATIENTS

Apart from psychological burden, multiple factors increase the prevalence of dermatoses among such patients. Anorexia-cachexia, malnutrition, anemia, metabolic alteration, immunosuppression (e.g., prolonged steroid in many cancers), immobilization and difficult to move for proper skin care, neurological disorders, etc., are some among them.[4]

CLASSIFICATION

Although there is no standard classification in the area of palliative dermatology, we would like to suggest dividing dermatoses into two major groups:

(1) dermatoses developing in palliative care patients and (2) dermatoses requiring palliative care.

The pattern of dermatoses among palliative care patients: Unfortunately, this area has not been studied extensively yet. It can range from simple xerosis to opportunistic infections and malignancies.[5] Lack of basic awareness programs for volunteers and general physicians in a palliative team, to diagnose simple dermatological conditions, leads to improper management. In one study, 80% of the patients had uncomfortable but treatable dermatoses, of which 62% were undocumented or incorrectly documented.[6] Steroid-containing combination drugs are extensively used in this field which leads to many complications such as recalcitrant superficial mycoses and skin atrophy.

DERMATOLOGICAL CONDITIONS REQUIRING PALLIATIVE CARE

As the dermatology branch spread its wings to include most of the autoimmune and malignant conditions, death in dermatology ward is not so uncommon these days.[7] This prompts dermatologists to master some of the arts of palliation. In Western countries, the most common cause of death in dermatology ward is cutaneous malignancies with melanoma in prime position, while in India, it may be autoimmune disorders. However, many recent articles show an increase in nonmelanoma skin malignancies in countries such as India, due to weather changes.[8] Hence, dermatologists may have to deal with the end-stage management of cutaneous malignancies in the future. Autoimmune conditions such as systemic sclerosis, which ultimately become fatal irrespective of advancement in available therapeutics, essentially require palliative management at some stage of the disease. Management of unfortunate genodermatoses such as dystrophic epidermolysis bullosa also will require palliative care protocols at least for pain management.

CURRENT SCENARIO

Dermatologists are not included in most of the palliative care teams including hospice services currently. Skin diseases are most often ignored by volunteers, physicians, relatives, and even by the patient himself/herself. Common tendency to belittle dermatological conditions adds to this situation. The impact of dermatoses on patient's mental and emotional status is not being addressed correctly. Even incidents of shaming seriously ill patients for complaining about cosmetic issues happened in our experience. A casual approach to treatment with combination topical agents is prevalent even in hospices.

FUTURE PROSPECTS

There is an absolute scarcity of scientific studies on the subject. Publications on epidemiologic and pathogenic aspects of dermatoses in palliative patients are highly warranted. Policymakers of palliative medicine should seriously take account to include dermatologists in the team and to educate about common dermatoses to its active service providers. A dermatologist may avail basic training in palliative care as it may aid him/her to address a certain situation in a better way than today.

CONCLUSIONS

Inclusion of dermatologists among palliative care team is essential for proper and timely management of dermatoses among patients under palliative care. Skin conditions even among terminally ill patients should not be neglected as they can further reduce their quality of life. Proper training about diagnosis and treatment of common dermatoses to the palliative care volunteers is essential for effective management.