CUTANEOUS CROHN'S DISEASE
Description
🔹 Definition:
# Cutaneous Crohn's disease is an uncommon extra-intestinal form of Crohn's disease in which the skin becomes inflamed with granules.
# It may happen:
• Contiguously (direct extension from intestinal illness, such as enterocutaneous fistulas or perianal fistulas).
• Non-contiguously: granulomas in skin at locations far from the gastrointestinal system (metastatic Crohn's disease).
🔹 Epidemiology:
• Affects between 20–40% of patients with Crohn's disease (total skin involvement).
• Less than 1% of people have metastatic cutaneous Crohn's disease.
• Although it can affect both sexes, intestinal Crohn's disease typically manifests in young adults.
🔹Pathophysiology:
# The precise cause is unknown, however it is believed to involve:
• Atypical T-cell response due to immunological dysregulation.
• Non-caseating granulomas in the dermis due to granulomatous inflammation.
• GI tract antigen translocation → cutaneous immune response.
• Linked to malnourishment and systemic inflammation.
🔹 Clinical Presentation:
# Types of Crohn's disease skin involvement:
1. Specific (granulomatous) lesions: • Metastatic Crohn's disease: ulcers, plaques, or granulomatous nodules at distant locations (facial, genitalia, arms, legs, or trunk).
• Fissures, fistulas, ulcers, and abscesses are examples of perianal/peristomal Crohn's disease.
2. Reactive lesions (not granulomatous, but immune-mediated):
•Erythema nodosum, which are sensitive red nodules on the shins.
• Pyoderma gangrenosum, which is characterized by painful ulcers with weakened margins.
• Tender plaques and fever are symptoms of Sweet's syndrome.
3. Lesions associated with treatment:
• Skin thinning brought on by steroids.
• Lesions resembling psoriasis were brought on by biologic therapy (anti-TNF).
🔹The characteristics of a cutaneous lesion:
# Include deep, painful, uneven borders, and the potential for discharge.
# Nodules/plaques: painful, inflammatory, reddish-brown.
# Abscesses and fistulas are frequent in the perianal and peristomal regions.
# Distribution: genitalia, perianal region, stoma sites, extremities, and intertriginous areas.
🔹Associated symptoms :
•Include soreness, edema, and pain.
• Bacterial secondary infection.
• Malaise and fever.
• Co-occurring gastrointestinal symptoms include malnourishment, weight loss, diarrhea, and abdominal pain.
🔹 Investigations :
• A skin biopsy reveals non-caseating granulomatous dermal inflammation.
•Cultures: to rule out tuberculosis, fungus, or bacteria. To confirm Crohn's disease, a colonoscopy is performed.
• Lab tests: dietary deficits, elevated ESR/CRP, and anemia.
🔹 Complications:
• Chronic ulcers that don't heal.
• Secondary infections (abscess, cellulitis).
• Formation of fistula.
• Excruciating pain and limited mobility.
• Psychological effects (depression, altered body image).
🔹 Management:
#Overall Guidelines:
• Address the underlying causes of Crohn's disease.
• Reduce localized inflammation and encourage recovery.
• Prevent subsequent infections and cure them.
• Promote mental and nutritional well-being.
🔹Medical Management:
#Systemic therapy:
• IV or oral corticosteroids.
• Immunosuppressants (methotrexate, azathioprine).
• Biochemical treatment (anti-TNF: adalimumab, infliximab).
#Topical therapy:
• Creams and ointments containing corticosteroids.
• Tacrolimus cream (for lesions that don't go away).
•Antibiotics: in the event of a subsequent infection.
🔹 Surgical Management:
• Abscess drainage. Surgery for fistulas.
• If necessary, stoma care.
🔹 Prognosis:
•The prognosis is chronic and recurrent.
•When systemic Crohn's disease is treated, skin lesions frequently become better.
• In certain situations, they could be resistant to treatment.
•Requires ongoing multidisciplinary care from a surgeon, dermatologist, gastroenterologist, and nurse.
🔹Case Report:
#Patient: R.K., a 19-year-old female
#History:
• Nodular lesions on the extremities for two weeks
•Abdominal pain and watery diarrhea are linked to fever and ill health.
# Examination:
• Skin: Abscess of the left forearm, skin lesions with non-infiltrated inflammatory border (left foot, right calf)
• Investigations:
✓ Skin biopsy: inflammatory infiltrate of deep dermis with tuberculoid non-caseating granulomas
# Colonoscopy:
•Multiple ulcers
•"Cobblestone appearance" of bowel
•Segmental colitis
# Complication:
•Steroid therapy was avoided due to post-colonoscopy peritonitis
• Follow-up colonoscopy: colon polyps
• Skin biopsy: colitis and "follicular" duodenitis
#The course of treatment included: • Colostomy
• Intravenous nutrition
• Resolution of skin lesions
Protocol
🔹Issues Nurses Face in Cutaneous Crohn's Disease:
1. Impaired Skin Integrity:
• Non-healing abscesses and ulcerated lesions.
• The likelihood of a subsequent bacterial infection is high.
2. Pain and Discomfort:
• Pain from abscesses and ulcerated lesions.
• Mobility issues if the lesions are on the extremities.
3. Infection Risk:
•As a result of immunosuppressive treatment (biologics/steroids), open skin sores, and inadequate nutrition.
4. Imbalanced feeding:
• Often necessitates parenteral feeding
• Weight loss and poor wound healing due to malabsorption and diarrhea.
5. Modified Body Image: •Psychological anguish is brought on by visible skin lesions and, if present, a stoma.
•Social isolation, anxiety, and sadness could emerge.
6. Complication Risk:
• Slow wound healing.
• Adverse reactions to immunosuppressive or steroid treatments.
• Complications from surgery, such as the development of fistulas.
🔹 Nursing Management:
1. Skin and Wound Care:
•Conduct routine evaluations of wounds (size, depth, exudate, infection) as part of nursing management for cutaneous Crohn's disease.
• To avoid infection, use sterile dressings.
• Use topical medications (steroid creams, antibiotics, etc., if prescribed).
•Promote good hygiene while steering clear of irritants.
• Keep an eye out for symptoms of a systemic infection or cellulitis, such as fever, erythema, or discharge.
2. Pain Management:
•Use pain scales to measure pain on a regular basis.
• Administer analgesics as directed (NSAIDs are normally avoided because of GI risk).
• Employ non-pharmacological techniques, such as positioning, warm compresses, and relaxation.
3. Nutrition Support:
•Work with a dietitian to create a diet that is high in calories, protein, and vitamins.
• Maintain electrolyte balance and hydration.
• If necessary, administer parenteral nourishment, particularly during acute flare-ups.
• Track weight and lab results (iron, vitamins, albumin).
4. Prevention of Infection:
• Using aseptic method when changing dressings.
• Teach the patient how to take care of their wounds and hands.
• Keep an eye out for systemic infections, particularly if you're on immunosuppressants.
5. Psychosocial Support:
•Offer emotional support and counseling in relation to stomas or visible skin sores.
• Promote involvement in Crohn's disease support groups.
•Teach the patient's family about flare-up management, medication compliance, and the course of the illness.
6. Patient education:
• Stress the value of taking medications as prescribed (biologicals, steroids, and immunosuppressants).
• Describe skin care practices and infection warning indicators.
• Avoiding stress by not smoking, which exacerbates Crohn's disease. • Promote stress-reduction strategies because stress frequently sets off flare-ups.
Notes
https://doi.org/10.1016/s0755-4982(06)74558-4