ERYTHRODERMA
Jessica Bartfield, M.D.
August, 2005
Introduction
 Exfoliative erythroderma refers to diffuse and generalized erythema and scaling of the skin involving
at least 50% and up to 90% of the body.
 Erythroderma is a morphologic presentation of a variety of dermatoses, infections, malignancies, and
other systemic diseases.
Etiologies
 Dermatoses (primary diseases of the skin) MOST COMMON CAUSE
 Psoriasis, atopic dermatitis, contact dermatitis, superficial pemphigus, bullous pemphigoid
 Drugs (a sampling of a very lengthy list)
 Antibiotics – PENICILLINS, antimalarials, anti-retrovirals (ddI, AZT), gentamicin, isoniazid,
streptomycin, sulfonamides, trimethoprim, vancomycin
 Gold, Mercury
 Antiarrhythmics – amiodarone, mexilitine, quinidine
 Antiepileptics – BARBITUATES, carbamazapine, phenobarbitol, phenytoin
 Antihypertensives – captopril, diltiazem, nifedipine
 Antiinflammatory – ASA, sulfasalazine
 Antipsychotics / mood stabilizers – chlorpromazine, lithium, other phenothiazines
 Antiulcer – cimetidine, omeprazole, ranitidine
 Chemotherapeutic – cisplatin
 Hematologic malignancies- 10% of cases of generalized erythroderma
 LYMPHOID MOST COMMONHodgkin’s, B-cell lymphoma, anaplastic large cell lymphoma
 10-20% of “idiopathic” erythroderma will go on to develop T-CELL LYMPHOMA Sezary
syndrome
 Solid tumors
 Prostate, lung, thyroid, liver, breast, ovarian
 Systemic diseases
 Subacute cutaneous lupus, dermatomyositis, acute GVHD, sarcoidoisis
 Thyrotoxicosis
Epidemiology
 Average age of onset is 41-61 years.
 Male predominance: male-to-female ratio 2:1 to 4:1 or higher.
Clinical Presentation
 Clinical features vary according to the underlying etiology.
 Time course may also be variable – SLOWER onset if associated with a preexisting skin condition,
MORE ACUTE suggests drug-induced or malignancy
 PRURITIS, ectropion, generalized lymphadenopathy, malaise, and pain most common symptoms.
Physical Examination
 Fevers or hypothermia, tachycardia, hypotension may indicate severity of presentation.
 Alopecia, keratoderma, nail dystrophy, and ectropion may be present in cases of longstanding
erythrodererma.
 Evidence of specific underlying diseases:
 Psoriasiform plaques, evidence of psoriatic arthritis, psoriatic nail changes in psoriasis
 Tense blisters in erythrodermic bullous pemphigoid
 Heliotrope rash, Gottron’s papules, poikiloderma, and muscle weakness in dermatomyositis
 Peripheral edema found in up to 50% of patients
 Lymphadenopathy with organomegaly may point towards malignancy or drug hypersensitivity.
Diagnosis- Based on history and physical exam, no routine labs, and biopsy may be inconclusive, as
histology is often non-diagnostic (diagnostic accuracy reported as 53%)
Beth Israel Deaconess Medical Center Residents’ Report
Complications
 Thermoregulatory disturbance –increased heat losses via dilated cutaneous vessels
 Fluid and electrolyte imbalances
 Hypoalbuminemia and malnutrition – daily protein loss increased by 25% in psoriatic erythroderma
 High output heart failure – possibly secondary to increased blood flow through cutaneous vessels
 Liver and renal dysfunction (more common in hypersensitivity reactions)
 Acute respiratory distress syndrome and capillary leak syndrome
 Infection – the primary cause of death in patients with erythroderma bacterial superinfections
Therapy HYDRATION AND NUTRITION
 Warm, humidified environment
 Fluid and electrolyte replacement
 Local skin care: oatmeal baths, wet dressings to weeping or crusted sites followed by bland
emollients and low-potency topical corticosteroids. High potency topical steroids are usually avoided
due to concerns for systemic absorption. Avoid skin irritants.
 Sedating oral antihistamine advocated for treatment of pruritis and anxiety
 Systemic therapy dictated by underlying diagnosis
Prognosis
 Depends
on cause, but case series have documented erythroderma-related death rates from
0% to 64%
Beth Israel Deaconess Medical Center Residents’ Report
Beth Israel Deaconess Medical Center Residents’ Report