Recognizing And Treating Cutaneous Issues Due To Flooding

With the rise (no pun intended) of natural disasters resulting in flooding events across the United States, it is helpful for the clinician to recognize the various lower extremity cutaneous issues that may befall patients in the flood zone. In a recent article, Bandino and colleagues reviewed some of the possible cutaneous skin infections following a natural disaster.¹

Flooding should immediately bring to mind immersion injuries. Standing in water, holding on to branches or finding other ways to rescue oneself may put the person in contact with a sharp object that will result in a laceration. Floodwaters are often contaminated with sewage, leading to exposure of various pathogens that can potentially create skin infections. Skin infections were the most reported cutaneous event following Hurricane Katrina in 2005 and the Asian tsunami in 2004.¹ Following the Pakistan floods in 2010, skin infections surpassed acute diarrhea and acute respiratory infections.¹

As you would suspect, Streptococcus and methicillin-resistant Staph aureus (MRSA) are the biggest pathogens to contend with in these incidents. In addition, organisms like Vibrio (occurring after Hurricane Katrina) and Aeromonas hydrophila (occurring after the Asian tsunami), which are present in environments naturally, are present at a pathogenic level during a flooding event.¹ To make matters worse, Vibrio may present as a necrotizing fasciitis-like situation with hemorrhagic bullae. Similar to the management of necrotizing fasciitis caused by Strep, treatment would consist of surgical debridement and systemic antibiotics. For Vibrio, use a doxycycline or a quinolone in addition to a third-generation cephalosporin. 

Besides bacteria, fungal infections caused by organisms typically present on decaying plant and soil matter can penetrate lacerated skin. One should suspect chromoblastomycosis, caused mostly by Fonsecaea pedrosoi, if the flooding event occurred in subtropical or tropical areas. Presentation-wise, this fungal disease may present as a generally painless papule, plaque or even a verrucous lesion. If you are treating a patient who has a non-healing wound following exposure to flooding, consider a fungal diagnosis. Do a KOH/culture in order to place the patient on the appropriate systemic antifungal. Surgical excision, heat therapy and/or cryotherapy may also be necessary. 

As you would expect, superficial fungal infections often occur after a flood. Tinea corporis occurred frequently following the Asian tsunami but as podiatric practitioners, we are extremely aware of tinea pedis manifesting both interdigitally and plantarly following exposure in these water-logged, humid environments.¹ In a perfect setting, we would prescribe patients the appropriate topical or oral antifungal. However, for those acting as emergency workers, they may only have gentian violet and miconazole in their tool kit. 

Contact dermatitis can occur as the patient may have been exposed to chemicals like pesticides or even poison ivy. Following Hurricane Katrina, Louisiana poison control centers reported exposures to gasoline and lamp oil.¹ As in the office, it can be challenging to discern the difference between an eczematous reaction and a fungal infection. A biopsy is always recommended to assist in the diagnosis of these challenging cases.   

This is just a sampling of this extensive review. If you are a practitioner in an area prone to or very recently ravaged by floods, I recommend that you read and keep this journal article for reference. 

Reference

1. Bandino JP, Hang A, Norton SA. The infectious and noninfectious dermatological consequences of flooding: a field manual for the responding provider. Am J Clin Dermatol. 2015; epub Jul 10.