WOC team takes primary role in skin management for a pre-teen with chemotherapy induced desquamation

July 2016, 11 year old morbidly obese female was admitted to a Pediatric Intensive Care Unit (PICU) in a Mid-Western tertiary Children’s hospital. One week prior to admission she was without symptoms. First day hospitalized, she was taken to the operating room to have a chest tube placed for pleural effusion, central venous access and biopsies of abdominal masses. She was diagnosed with Burkett’s Lymphoma (BL), a highly aggressive B cell neoplasm which is approximately 30% of pediatric lymphomas in US with an estimated incidence of three cases per million per year with 4:1 male dominant ratio in both children and adults. This 11 year old’s hospitalization has been complicated by septic shock, severe tumor lysis syndrome requiring hemodialysis, multiple infections, respiratory failure from pulmonary edema, typhlitis, severe exfoliative rash, severe mucositis, pancytopenia, and hemodynamic instability. PICU physicians consulted Plastics/Burn, Dermatology and WOC teams for treatment options for severe skin desquamation. Dermatology biopsied her skin and results revealed chemotherapy induced desquamation. Literature reviews shows chemotherapy induced acral erythema (CIAE) is an uncommon and dramatic reaction to high-dose chemotherapy, characterized by painful erythema of the palms and soles with possible bullae formation and desquamation. This pre-teen had 25%  total body surface area affected on her back, in skin folds, posterior neck, thighs and buttocks with painful denuded patchy skin, erythema and bullae formation. No literature was found for this severe skin desquamation related to chemotherapy. Multidisciplinary collaboration endorsed the WOC team to take primary lead in skin management.  Prevention of infections, skin injuries and pain management were priorities. Treatment included pain medication prior to bathing with soft foaming wash cloths, humectant & emollient application to maintain moisture, hydrophilic wound dressing to open wounds and a silver absorbent pad to wick away drainage. WOC direction and vigilant nursing care generated positive outcomes.