How to manage blisters and skin sloughing in patients with Multiple System Atrophy (MSA)?

Management of Blisters and Skin Sloughing in Multiple System Atrophy

Blisters and skin sloughing in MSA patients are most commonly pressure ulcers from immobility and should be managed with meticulous wound care, pressure-relieving surfaces, and infection prevention—not as drug reactions or autoimmune blistering disorders.

Initial Assessment and Differential Diagnosis

The first critical step is determining the underlying cause of blistering and skin sloughing in your MSA patient:

• Perform thorough skin examination focusing on pressure-prone areas including sacrum, ischia, heels, and other bony prominences, as MSA patients are frequently bedridden 1
• Document lesion characteristics: measure size in centimeters, assess for epidermal detachment, evaluate for signs of infection (warmth, purulence, odor) 1
• Rule out drug-induced causes if the patient is on any new medications, particularly if there is mucous membrane involvement or widespread distribution 2
• Rule out Stevens-Johnson syndrome/TEN if there is extensive epidermal detachment with systemic symptoms, though this is unlikely in the MSA context without recent drug exposure 2, 1

Common pitfall: MSA patients develop skin breakdown primarily from immobility, autonomic dysfunction affecting skin perfusion, and urinary incontinence—not from autoimmune or drug-induced causes. The guidelines on SJS/TEN and immune-related adverse events 2 are not applicable unless there is clear drug exposure or systemic involvement.

Wound Care Management

Conservative Approach (First-Line for All Patients)

Cleansing and topical management:

• Gently irrigate wounds using warmed sterile water, saline, or diluted chlorhexidine (1/5000) 2, 1
• Apply greasy emollients such as 50% white soft paraffin with 50% liquid paraffin over the entire epidermis, including denuded areas 2
• For blisters: decompress by piercing and expressing or aspirating fluid, but leave the detached epidermis in place to act as a biological dressing 2
• Apply topical antimicrobials (silver-containing products) only to sloughy or potentially infected areas, not prophylactically 2, 1

Dressing selection:

• Apply non-adherent dressings to denuded dermis (Mepitel™ or Telfa™) 2, 1
• Use secondary foam or burn dressings to collect exudate (Exu-Dry™) 2, 1
• Consider hydrocolloid dressings for non-infected wounds 1

Pressure Relief and Environmental Control

• Use air-fluidized beds for large pressure ulcers (>7 cm), as moderate-quality evidence shows they reduce ulcer size 1
• Maintain ambient temperature between 25°C and 28°C to promote healing 2, 1
• Place patient on pressure-relieving mattress with controlled humidity 2

Infection Prevention and Monitoring

Critical surveillance approach:

• Employ strict barrier nursing to reduce nosocomial infections 2, 1
• Take bacterial and candidal cultures from three areas of lesional skin, particularly sloughy areas, on alternate days during acute phase 2
• Administer systemic antibiotics ONLY if clinical signs of infection are present—do not use prophylactically 2, 1
• Monitor for signs of systemic infection: confusion, hypotension, reduced urine output, decreased oxygen saturation, rising C-reactive protein 2

Common pitfall: Indiscriminate prophylactic antibiotics increase skin colonization with Candida albicans and resistant organisms 2.

Nutritional Support

MSA patients with extensive skin breakdown require aggressive nutritional support:

• Provide continuous enteral nutrition via oral route or nasogastric tube if oral intake is compromised 2
• Deliver 20-25 kcal/kg daily during the early catabolic phase 2
• Increase to 25-30 kcal/kg daily during the anabolic recovery phase 2
• Provide protein-containing supplements as moderate-quality evidence shows they improve wound healing 1

Advanced Therapies for Non-Healing Wounds

If wounds fail to improve with conservative management:

• Consider electrical stimulation as adjunctive therapy (moderate-quality evidence for accelerating healing) 1
• Consider platelet-derived growth factor (PDGF) for large or non-healing ulcers 1
• Consider negative-pressure wound therapy for appropriate wounds 1
• Consult specialists (dermatology, wound care, plastic surgery) for complex cases 1

Pain Management

• Provide adequate background analgesia using the WHO analgesic ladder principles 2
• Initiate opiate-based regimen (morphine) for moderate-to-severe uncontrolled pain 2
• Monitor closely for level of consciousness, respiratory rate, and oxygen saturation when using opiates 2

When to Escalate Care

Transfer to burn center or ICU if:

• >10% body surface area (BSA) epidermal loss with clinical deterioration 2
• Evidence of extension of epidermal detachment 2
• Local sepsis or subepidermal pus 2
• Delayed healing or wound conversion (progression to deeper defects) 2

Critical distinction: The extensive guidelines for SJS/TEN management 2 involving high-dose corticosteroids and ICU admission are NOT appropriate for pressure ulcers in MSA patients unless there is confirmed drug-induced severe cutaneous adverse reaction, which would be exceedingly rare in this population.