Cutaneous Manifestations Following Exposures to Marine Life Treatment & Management

Patients are usually seen in the dermatologist's office several hours or days after the initial injury. By the time of this encounter, the patient might already have undergone emergency treatment, including the use of specific measures such as the use of antivenins.

Evaluate the nature of the initial lesion and ask patients to describe any first aid measures that have been applied.

If a foreign body is found or suspected, evaluate for deeper penetration. When in doubt, perform appropriate radiographic examinations. See Surgical Care for surgical evaluation. Remove the foreign body and close the wound if not infected. Consider using broad-spectrum oral antibiotics.

In case of erythema, vesiculation, or blistering, instruct the patient regarding appropriate care. Prevent secondary infection by meticulous wound care and by protecting denuded areas. Topical corticosteroids are beneficial in combating the local reactions. Systemic steroids may be indicated in severe cases.

Pain can be managed with analgetics selected according to severity of pain, pain tolerance of the patient, and other considerations (eg, age, presence of other medical problems).

Scars or keloids causing disfigurement or functional limitations may be treated surgically.

A case report described treatment of stonefish envenomation caused by cutting a stonefish during food preparation. The patient's hand was immersed in hot water and the signs and symptoms of the hand resolved within 18 hours. ^[19]   Similarly, in a case when a tourist stepped on a stonefish and parenteral and local anesthesia were ineffective, soaking the foot in hot water relieved the pain. ^[20]

Surgical care depends on the nature of the injury and the available level of medical care. In emergency situations, initiate first aid measures. Remember to exercise caution when removing animals or animal parts because these may still contain toxins or foreign bodies that can be harmful to both the patient and the physician.

First steps during acute care include controlling bleeding, cleaning the wound, removing visible foreign bodies (including sand), and covering with a (preferably sterile) dressing. Absorption of a toxin can be delayed by applying pressure over the wound and by placing elastic bandages approximately 15 cm (6 in) both distally and proximally of the wound. Check circulation periodically; arterial pulses should be detectable. In addition, immobilizing the patient or at least the affected area (eg, splinting the extremity, placing a sling) could help in delaying the absorption of the venom.

Stings can be neutralized by irrigation with vinegar, baking soda (paste prepared with water), salt water, or papain powder or solution (meat tenderizer). Remove tentacles only after adequate neutralization. Remove sea urchin spines if possible. Submerse the affected area in hot water (up to 45°C or 113°F), scrub with water and soap, and irrigate copiously with fresh water. Remove deeply lodged spines after careful evaluation. Hot water immersion has also been suggested for nonpenetrating marine envenomation. ^[21] Depending on the depth of the puncture wound, longer incubation times may be needed for the heat to penetrate the deeper portions of the skin to be effective in deactivation of the venom. ^[22]

Although vinegar completely inhibited cnidae firing under experimental conditions, newly developed proprietary formulations containing copper gluconate, magnesium sulfate, and urea seemed to be more effective to inhibit both tentacle firing and subsequent venom-induced hemolysis. ^[22]

Nematocysts can discharge their contents on exposure to fresh water; therefore, irrigation of the exposed areas with fresh water is contraindicated. For the same reason, be sure that melting ice, applied for local pain control, cannot irrigate the wound site before neutralization.

Assessing the need for further surgical care depends on the following:

• Foreign bodies remaining in the wound and how deeply they may be lodged: Ideally, all foreign bodies should be removed because they can cause further toxin release, infection, granuloma formation, and functional limitations.

• The presence of infection: In this case, obtain specimens for culturing. Initiate broad-spectrum antibiotic treatment and modify according to clinical response and culture results.

• Cyanosis or necrosis: Determine the cause and initiate appropriate management.

• Necessary debridement: Apply basic wound care measures as necessary.

• Scarring: Any scarring that would be functionally limiting or cosmetically unacceptable. Consider treatment with intralesional steroid injections or surgical reconstruction.

• Need for prosthetic replacement of a limb or its part: Subspecialty consultation may be appropriate.

Consult specialists as required by the type of injury or complication (eg, orthopedic surgeon in case of joint or bone involvement, plastic surgeon in cases of extensive scars, infectious diseases specialist for complicated primary or secondary infections).