Nurses have a pivotal role in conveying to the care team accurate, timely skin assessments of patients with graft-versus-host disease (GVHD). This critical information helps the team diagnose skin GVHD, determine its staging and grading, and monitor patients’ response to treatment.
Since the skin is the most common clinical manifestation of both acute and chronic GVHD, nurses need to be proficient in using tools like the Rule of Nines to determine the extent of the body surface area (BSA) affected.
What Is the Rule of Nines?
Most nurses learn about the Rule of Nines in nursing school as it is a standard tool to estimate second-degree and third-degree burn involvement.
The tool divides the body into sections using multiples of 9% each. This tool is for adults and older children (generally, older than 14 years of age)—a modified version is necessary for infants and young children.
From head to toe, the sections of the Rule of Nines are:
- Head: 9%
- Torso: 36%
- Arms: 18%
- Legs: 36%
- Groin: 1%
The different body sections can be divided into smaller sections. For example, the front of the head is 4.5% and the back of the head is 4.5% for a total of 9%. Each leg is 18%, so 36% for both legs, and each arm is 9% for 18% total.
Why Is the Rule of Nines Helpful in GVHD?
The Rule of Nines helps determine the percentage of the BSA affected, which is critical for staging the skin as a target organ. The Arabic numbers 0-4 define the skin GVHD stage, which subsequently helps determine the grade.
|Stage 0||No rash|
|Stage 1||Rash <25% of BSA|
|Stage 2||Rash 25%-50% of BSA|
|Stage 3||Generalized erythroderma|
|Stage 4||Generalized erythroderma with bullous formation and desquamation|
Skin staging and subsequent grading help guide topical management with steroid or tacrolimus creams or systemic steroid treatment.
How Do You Use the Rule of Nines?
Using a head-to-toe approach provides a systematic examination of the skin for each area. Start with the patient sitting on the edge of the bed or exam table, keeping the patient covered except for the portion of the body you are currently assessing.
Examine each section of the skin with a 3-step approach: see, touch, stage.
- See: What do you see on each surface area—anterior and posterior? How would you describe it? Where exactly is the location (eg, upper and lower arm, only on the tops of ears)?
- Touch: Is it warm to the touch? Does the skin weep or peel? Does the patient complain of discomfort with light palpation?
- Stage: What is the affected percentage of each area? Consider recording it as you proceed.
Your findings will be slightly different depending on whether the patient has acute or chronic GVHD. Acute GVHD of the skin can range from erythema or a maculopapular rash to blistering, peeling, or widespread skin loss. Because of its scleroderma-type manifestations, chronic GVHD of the skin typically presents more as scaly or flaky, or like a shiny scar, with darker or lighter areas of the skin.
Familiarity with the Rule of Nines tool is critical to be able to provide accurate estimates. Centers may use a body map, smartphone, or computer application to reduce overestimating or underestimating errors. And be sure to include the groin area. Although it is only a tiny area accounting for 1% of the BSA, it is often an area of discomfort and concern for patients, particularly those with chronic GVHD.
Nurses have a key role in discussing body shapes with providers because not all patients have an hourglass shape or are as fit as the tool design. Those patients with a pear or apple shape may have a different distribution of BSA. Obese patients may have higher numbers for their trunk with lower numbers for arms. As the degree of obesity increases, the degree of BSA may need to adapt. Individualizing this standardized tool is critical for providing patient-centered care.
Schmit-Pokorny, Eisenberg S. Acute and chronic graft-versus-host disease. In: Hematopoietic Stem Cell Transplant: A Manual for Nursing Practice, Third Edition. Pittsburgh, PA: Oncology Nursing Society; 2020. p. 133-183.