Cutaneous Injury

Skin 1. Poikiloderma, pigmentation disorders 2. Scarring 3. Eczema 4. Dry skin conditions 5. Prurigo 6. Cherry-like hemangioma 7. Hair loss in affected areas 8. Telangiectasis 

Eyes 1. Chronic conjunctivitis 2. Corneal opacification 3. Corneal ulcerations and erosions 4. Stromal scarring 5. Limbal pigmentation 6. Limhal stem cell deficiency 7. Neovascularization (torted vessels) 

Respiratory tract 1. Bronchiolitis obliterans 2. Bronchial stenosis 3. Neovascularization and tracheal vulnerability 4. Chronic cough with blood sputum 5. Diminished mucociliary clearance 6. Interstitial lung disease 7. Emphysema 

Poikiloderma (hypo- and hyper-pigmented areas) on the back of a patient in the region of the mustard gas exposure. Skin regions protected by a belt developed fewer late effects. 

Hair loss as well as hypo- and hyper-pigmented areas in the axillae of a patient after SM exposure. 

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Carbamate nerve agents do not have good warning properties. They have no odor, and, other than causing miosis, aerosols do not irritate the eyes. Contact neither irritates the skin nor causes cutaneous injuries. 

Renshaw, B. Mechanisms in production of cutaneous injuries by sulfur and nitrogen mustards. IN Chemical Warfare Agents, and Related Chemical Problems, 2 vol. (Summary Technical Report of Division 9, National Defense Research Cornmittee.) Washington, D.C. U.S. Office of Scientific Research and Development. 1946. p. 479-518. 

Ballantyne, B. and Johnston, W.G. o-Chlorobenzylidene malono-nltrlle (CS) and the healing of cutaneous injuries. Med. 

Hiroshima N, Shinogi T, Sakashita N, Narisawa Y. A case of cutaneous injury induced by the subcutaneous injection of leuprolide acetate. Nishinihon J Dermatol 2001 63 384-6. 

Dorschner, R.A., Pestonjamasp, V.K., Tamakuwala, S et al. (2001) Cutaneous injury induces the release of cathelicidin anti-microbial peptides active against group A streptococcus. J. Invest. Dermatol. 117, 91-97. 

Upon systemic distribution, many drugs evoke skin reactions that are caused on an immunological basis. Moreover, cutaneous injury can also arise from nonimmunological mechanisms. Cutaneous side effects vary in severity from harmless to lethal. Cutaneous reactions are a common form of drug adverse reaction. Nearly half of them are attributed to antibiotics or sulfonamides, and one-third to nonsteroidal anti-inflammatory agents, with many other pharmaceuticals joining the list... 

Although burns are cutaneous injuries, the effects can influence nearly all systems of the body. The overall morbidity associated with a burn injury will be determined by burn depth, percentage total body surface area (TBSA) involved, patient age, and presence of inhalation injury. Children and older adults have thinner skin and are more likely to sustain a deeper burn injury. Patients at the age extremes are also less likely to tolerate the stress of burn shock. The presence of an inhalation in-... 

Electrical injuries often require more extensive IV fluid resuscifafion fhan calculated by the Parkland formula because the extent of subcutaneous and deep tissue involvement is usually underestimated by the apparent cutaneous injury. A sample of fhe pafient s urine should be obtained initially and kept for comparison to subsequent samples to assess clearing of fhe pigment. 

Casillas, R.P., Kiser, R.C. (2000). Therapeutic approaches to dermatotoxicity by sulfurmustard. I. Modulaton of sulfur mustard-induced cutaneous injury in the mouse ear vesicant model. J. Appl. Toxicol. 20, Suppl. 1 SI45-51. 

Ruff, A.L., Dillman, J.F. (2007). Signaling molecules in sulfur mustard-induced cutaneous injury. Eplasty 8 e2. 

Smith, K.J. (1999). The prevention and treatment of cutaneous injury secondary to chemical warfare agents. Application of these finding to other dermatologic conditions and wound healing. Dermatol. Clin. 17(1) 41-60. 

Depending on the dose, dose rate and route of exposure, radiation can cause Acute Radiation Syndrome (ARS), cutaneous injury and scarring, chorioretinal damage (due to exposure to infrared energy), and increased long term risk for cancer, cataract formation (especially due to neutron irradiation), infertility and fetal abnormalities, such as growth retardation, fetal malformations, increased teratogen-esis and fetal death (2). 

Some skin damage frequently accompanies ARS. However, the cutaneous syndrome can also result from localized acute radiation exposure to the skin, usually from direct handling of radioactive sources or from contamination of the skin or clothes (2,8) (see Figs. 4.1 and 4.2) With localized exposure, even with high doses, the victim frequently survives, because the whole body usually does not receive the localized dose. However, if a patient with localized radiation induced cutaneous injury has also received whole body irradiation from an external source, the cutaneous damage increases the risk for death from the whole body exposure (2). Patients with the hematopoietic syndrome due to whole body irradiation will recover more slowly, if at all, from cutaneous injury due to bleeding, infection and poor wound healing (2). 

Compared to thermal bums, radiation induced bums develop more than a week after exposure. Therefore, patients presenting with bum injuries immediately after exposure are suffering from thermal rather than radiation bums. Table 4.3 illustrates the relationship between exposure dose and cutaneous injury. 

Renshaw B (1946). Mechanisms in production of cutaneous injuries by sulfur and nitrogen mustards. In Summary Technical Report of Division 9, NDRC,... 

In addition to the direct effects which sulphur mustard may have in initiating proteolytic cascades, other sources of proteolytic enzymes have to be considered, the most important of these being the various inflammatory cell types that have been described as part of the sulphur mustard-induced cutaneous injury in various species (Papirmeister et al, 1984 Vogt et al., 1984 Mitcheltree et al, 1989 Mershon et al., 1990). 

Although microscopic descriptions of World War I vesicant agent-induced lesions exist, more recently Papirmeister et al. (1985) have described a model (full-thickness human neonatal foreskin grafted to congenitally athymic nude mice) which appears to reproduce very accurately the findings previously described. This model has also allowed lesions to be studied at the ul-trastructural level in an attempt to reveal additional information about the exact histogenesis of vesicant-induced cutaneous injuries. The observations made from this model can be summarised as follows. 

The severity of cutaneous injury appears to depend on the degree of alkylation occurring in the skin (Renshaw, 1940). Several dose regimens of liquid sulphur mustard were used, based on data derived from earlier studies by Renshaw (1947), viz ... 

The current clinical management of sulphur mustard cutaneous injury is essentially that for a similar degree of thermal burn (Mellor et al., 1991) but it is always important to bear in mind that the signs and symptoms of injury will not be evident for several hours after exposure. The overall management can be summarized as follows ... 

Renshaw B (1940). Mechanisms in the production of cutaneous injuries by sulphur and nitrogen mustards. In Chemical Warfare Agents and Related Chemical Problems, Volume 1, pp. 479-518. Washington, DC, USA US Office of Science Research and Development, National Defense Research Committee. 

The possibility that CS could modify the rate and/or mechanism of healing of cutaneous injuries was investigated in rats (Ballantyne and Johnson, 1974b). Compared to untreated control lesions, up to 10 mg CS applied to abrasions, full-thickness skin wounds, or burns, did not influence the rate of healing. 

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