eMedicine Specialties > Dermatology > Papulosquamous Diseases

Erythroderma (Generalized Exfoliative Dermatitis): Differential Diagnoses & Workup

Author: Sanusi H Umar, MD, FAAD, Attending Physician, Department of Dermatology, Charles R Drew/MLK Medical Center
Coauthor(s): A Paul Kelly, MD, Chief, Clinical Professor, Department of Internal Medicine, Division of Dermatology, King/Drew Medical Center, Charles R Drew University
Contributor Information and Disclosures

Updated: Aug 24, 2009

Differential Diagnoses

Acanthosis Nigricans
Lichen Planus
Atopic Dermatitis
Pemphigus Foliaceus
Bullous Pemphigoid
Pityriasis Rubra Pilaris
Contact Dermatitis, Allergic
Psoriasis, Plaque
Contact Dermatitis, Irritant
Reactive Arthritis
Cutaneous T-Cell Lymphoma
Sarcoidosis
Familial Benign Pemphigus (Hailey-Hailey Disease)
Seborrheic Dermatitis
Graft Versus Host Disease
Stasis Dermatitis

Other Problems to Be Considered

Etiologies of exfoliative dermatitis (see Causes)

Workup

Laboratory Studies

  • Increased erythrocyte sedimentation rate, anemia, hypoalbuminemia, and hyperglobulinemia are frequent findings.
  • Byer and Bachur2 report that the levels of glucose, calcium, and creatinine and the platelet and polymorphonuclear leukocyte counts are of prognostic significance in children who present with erythroderma and fever.
  • Increased IgE may be observed in exfoliative dermatitis (ED) when caused by atopic dermatitis.
  • Peripheral blood smears and bone marrow examination may be useful in a leukemia workup.
  • Immunophenotyping, flow cytometry, and particularly, B- and T-cell gene rearrangement analysis may be helpful in confirming the diagnosis if lymphoma is strongly suspected.
  • Skin scrapings may reveal hyphae or scabies mites.
  • Cultures may show bacterial overgrowth or the herpes simplex virus.
  • Perform HIV testing in the right setting; use polymerase chain reaction for viral detection, rather than enzyme-linked immunoassay, since exfoliative dermatitis has been reported to predict seroconversion in HIV infection.
  • In a report by Griffiths et al,3 decreased CD4+ T-cell count was observed in patients with exfoliative dermatitis in the absence of HIV disease.

Imaging Studies

  • Pursue further tests (eg, computed tomography scanning, magnetic resonance imaging, chest radiography, mammography) if the clinical features so indicate.

Other Tests

  • If the cause of exfoliative dermatitis is in doubt, survey patients for occult tumors or cancers. Perform chest radiography and routine cancer screenings appropriate for age and sex (eg, mammogram, stool occult blood test, sigmoidoscopy, prostate examination, serum prostate specific antigen level, cervical smear).
  • Patch testing can be performed to unveil contact allergens but should be performed only during periods of remission. In the patch test, include systemic drugs the patient was taking prior to the onset of exfoliative dermatitis.
  • Direct immunofluorescence studies diagnosed at least 2 reported cases of pemphigoid erythroderma, according to Scrivener et al.4

Procedures

  • Skin biopsies reveal nonspecific findings of spongiotic dermatitis; however, primary disease may be evident.

Histologic Findings

The appearance of exfoliative dermatitis usually masks the underlying disease's specific histologic features. The most common histopathologic appearance is of either subacute or chronic dermatitis; however, biopsy is indicated, since diagnostic findings are present in 40% of cases. A search for the underlying cause is necessary because of possible prognostic and therapeutic implications. Detailed histopathologic analysis with clinicopathologic correlation is mandatory in the remaining cases for which a specific cause is not apparent. Often, repeated biopsies and hematologic studies may be necessary to detect specific conditions (eg, cutaneous T-cell lymphoma). Repeated biopsies have been reported to result in a diagnosis in 50% of cases that do not reveal specific findings initially.

More on Erythroderma (Generalized Exfoliative Dermatitis)

Overview: Erythroderma (Generalized Exfoliative Dermatitis)
Differential Diagnoses & Workup: Erythroderma (Generalized Exfoliative Dermatitis)
Treatment & Medication: Erythroderma (Generalized Exfoliative Dermatitis)
Follow-up: Erythroderma (Generalized Exfoliative Dermatitis)
Multimedia: Erythroderma (Generalized Exfoliative Dermatitis)
References
Further Reading
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References

  1. Sigurdsson V, Toonstra J, Hezemans-Boer M, van Vloten WA. Erythroderma. A clinical and follow-up study of 102 patients, with special emphasis on survival. J Am Acad Dermatol. Jul 1996;35(1):53-7. [Medline].

  2. Byer RL, Bachur RG. Clinical deterioration among patients with fever and erythroderma. Pediatrics. Dec 2006;118(6):2450-60. [Medline].

  3. Griffiths TW, Stevens SR, Cooper KD. Acute erythroderma as an exclusion criterion for idiopathic CD4+ T lymphocytopenia. Arch Dermatol. Dec 1994;130(12):1530-3. [Medline].

  4. Scrivener Y, Cribier B, Le Coz C, Boehm N, Jelen G, Heid E, et al. [Erythroderma with immunoglobulin deposits along the basal membrane. Pemphigoid erythroderma?]. Ann Dermatol Venereol. Jan 1998;125(1):13-7. [Medline].

  5. Zackheim HS, Kashani-Sabet M, Hwang ST. Low-dose methotrexate to treat erythrodermic cutaneous T-cell lymphoma: results in twenty-nine patients. J Am Acad Dermatol. Apr 1996;34(4):626-31. [Medline].

  6. Sigurdsson V, Toonstra J, van Vloten WA. Idiopathic erythroderma: a follow-up study of 28 patients. Dermatology. 1997;194(2):98-101. [Medline].

  7. Bruno TF, Grewal P. Erythroderma: a dermatologic emergency. CJEM. May 2009;11(3):244-6. [Medline].

  8. Burton JL, Holden WE. Lichenification and prurigo. In: Champion RH, ed. Textbook of Dermatology. 6th ed. London, England: Blackwell Science; 1998:673-8.

  9. Cohen LM, Skopicki DK, Harrist TJ. Non-infectious vesiculobullous and vesiculopostular diseases. In: Elenitsas R, ed. Lever's Histopathology of Skin. 8th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 1997:216.

  10. Freedberg IM. Exfoliative dermatitis. In: Freedburg IM, Fitzpatrick TB, Goldsmith LA, et al, eds. Fitzpatrick's Dermatology in General Medicine. 5th ed. New York, NY: McGraw-Hill; 1999:534-7.

  11. Nakamura M, Tokura Y. Tocilizumab-induced erythroderma. Eur J Dermatol. May-Jun 2009;19(3):273-4. [Medline].

  12. Prakash BV, Sirisha NL, Satyanarayana VV, Sridevi L, Ramachandra BV. Aetiopathological and clinical study of erythroderma. J Indian Med Assoc. Feb 2009;107(2):100, 102-3. [Medline].

  13. Sehgal VN, Srivastava G. Exfoliative dermatitis. A prospective study of 80 patients. Dermatologica. 1986;173(6):278-84. [Medline].

  14. Torres-Camacho P, Tirado-Sánchez A, Ponce-Olivera RM. A study of erythroderma: clues from eosinophilia and elevated lactate dehydrogenase levels. Indian J Dermatol Venereol Leprol. Sep-Oct 2008;74(5):499-500. [Medline].

  15. Wong KS, Wong SN, Tham SN, Giam YC. Generalised exfoliative dermatitis--a clinical study of 108 patients. Ann Acad Med Singapore. Oct 1988;17(4):520-3. [Medline].

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Keywords

exfoliative erythroderma, ED, erythematous dermatitis, generalized exfoliative dermatitis, red man syndrome, idiopathic ED, idiopathic exfoliative dermatitis, erythrodermatitis

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Contributor Information and Disclosures

Author

Sanusi H Umar, MD, FAAD, Attending Physician, Department of Dermatology, Charles R Drew/MLK Medical Center
Sanusi H Umar, MD, FAAD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, and American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

A Paul Kelly, MD, Chief, Clinical Professor, Department of Internal Medicine, Division of Dermatology, King/Drew Medical Center, Charles R Drew University
A Paul Kelly, MD is a member of the following medical societies: American Academy of Dermatology, American Dermatological Association, American Medical Association, American Society for Dermatologic Surgery, National Medical Association, and Pacific Dermatologic Association
Disclosure: Nothing to disclose.

Medical Editor

James W Patterson, MD, Director of Dermatopathology, Professor of Pathology and Dermatology, Departments of Pathology and Dermatology, University of Virginia Medical Center
James W Patterson, MD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, American Medical Association, American Society of Dermatopathology, Medical Society of Virginia, Royal Society of Medicine, Society for Investigative Dermatology, and United States and Canadian Academy of Pathology
Disclosure: Nothing to disclose.

Pharmacy Editor

Richard P Vinson, MD, Assistant Clinical Professor, Department of Dermatology, Texas Tech University School of Medicine; Consulting Staff, Mountain View Dermatology, PA
Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Rosalie Elenitsas, MD, Herman Beerman Associate Professor of Dermatology, University of Pennsylvania School of Medicine; Director, Penn Cutaneous Pathology Services, Department of Dermatology, University of Pennsylvania Health System
Rosalie Elenitsas, MD is a member of the following medical societies: American Academy of Dermatology and American Society of Dermatopathology
Disclosure: Nothing to disclose.

CME Editor

Joel M Gelfand, MD, MSCE, Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania
Joel M Gelfand, MD, MSCE is a member of the following medical societies: Society for Investigative Dermatology
Disclosure: AMGEN Consulting fee Consulting; AMGEN Grant/research funds None; Genentech Consulting fee Consulting; Centocor Consulting fee Consulting; Centocor Grant/research funds None; Covance Consulting fee Consulting; Shire  Consulting

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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