Erythroderma (Generalized Exfoliative Dermatitis) Follow-up

  • Author: Sanusi H Umar, MD, FAAD; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Jan 24, 2012
 

Further Outpatient Care

  • Follow patients discharged from the hospital on an outpatient basis for continued management of underlying disease.
  • Closely follow patients with no discernible underlying disease (idiopathic exfoliative dermatitis [ED]) using multiple serial biopsies to exclude cutaneous T-cell lymphoma. Since low-dose methotrexate has been shown to be efficacious in the management of erythrodermic cutaneous T-cell lymphoma (as reported by Zackheim et al[9] ), some have advocated the use of methotrexate between rebiopsy periods in patients with idiopathic exfoliative dermatitis that is unremitting despite the use of topical steroids. However, this novel approach should be taken with the understanding that cutaneous T-cell lymphoma develops only in a minority of patients with idiopathic exfoliative dermatitis (7%), especially in the subgroup with persistent chronic disease on long-term follow-up care (as reported by Sigurdsson et al[10] ), and that methotrexate is associated with many adverse effects, including toxicities of the liver, lungs, and bone marrow.
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Inpatient & Outpatient Medications

  • Appropriate in/outpatient medications are influenced by the underlying etiology of exfoliative dermatitis. For example, prednisone may be contraindicated in exfoliative dermatitis secondary to psoriasis, while retinoids are an excellent choice for this disease.
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Transfer

  • Transfer patients with exfoliative dermatitis to the care of a dermatologist.
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Deterrence/Prevention

  • Prevention of exfoliative dermatitis depends on adequate control of underlying etiology. For example, gentle skin care is key to preventing exfoliative dermatitis flare-ups in atopic dermatitis, while specific treatments for psoriasis should be adhered to when it is the underlying cause.
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Complications

  • Complications in exfoliative dermatitis depend on underlying disease. Secondary infection, dehydration, electrolyte imbalance, temperature dysregulation, and high-output cardiac failure are potential complications in all cases.
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Prognosis

  • The prognosis of exfoliative dermatitis depends largely on underlying etiology.
  • The disease course is rapid if it results from drug allergy, lymphoma, leukemia, contact allergens, or staphylococcal scalded skin syndrome.
  • A study[5] of pediatric patients (age < 19 y) found that fever is a poor prognostic marker and may indicate a susceptibility to rapid deterioration. In this group, those with the following characteristics have a higher tendency to develop hypotension: age 3 years or younger, ill appearance, vomiting, glucose level of 110 mg/dL or less, calcium value of 8.6 mg/dL or less, platelet count of 300,000/μL or less, elevated creatinine value, polymorphonuclear leukocyte count of 80% or greater, and the presence of a focal infection. The risk of toxic shock syndrome is increased especially in children with erythroderma and fever who have the following additional features: age of 3 years or younger, ill appearance, elevated creatinine value, and hypotension upon arrival.
  • The disease course is gradual if it results from generalized spread of a primary skin disease (eg, psoriasis, atopic dermatitis).
  • The mean duration of illness typically is 5 years, with a median of 10 months.
  • The overall mortality is in the range of 20-40%; in 20% of fatalities, the cause of death is from factors unrelated to exfoliative dermatitis.
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Patient Education

  • Educate patients on the specifics of the underlying cause of their exfoliative dermatitis and the importance of diligent follow-up management as indicated.
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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 Drew University of Medicine and Science

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.

Specialty Editor Board

James W Patterson, MD  Professor of Pathology and Dermatology, Director of Dermatopathology, 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 Society of Dermatopathology, Royal Society of Medicine, Society for Investigative Dermatology, and United States and Canadian Academy of Pathology

Disclosure: Nothing to disclose.

Richard P Vinson, MD  Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster 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.

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: Lippincott Williams Wilkins Royalty Textbook editor; DLA Piper Consulting fee Consulting

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 Investigator; Genentech Grant/research funds investigator; Centocor Consulting fee Consulting; Abbott Grant/research funds investigator; Abbott Consulting fee Consulting; Novartis investigator; Pfizer Grant/research funds investigator; Celgene Consulting fee DMC Chair; NIAMS and NHLBI Grant/research funds investigator

Chief Editor

Dirk M Elston, MD  Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

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. Sarkar R, Garg VK. Erythroderma in children. Indian J Dermatol Venereol Leprol. Jul-Aug 2010;76(4):341-7. [Medline].

  3. Fraitag S, Bodemer C. Neonatal erythroderma. Curr Opin Pediatr. Aug 2010;22(4):438-44. [Medline].

  4. Yuan XY, Guo JY, Dang YP, Qiao L, Liu W. Erythroderma: A clinical-etiological study of 82 cases. Eur J Dermatol. May-Jun 2010;20(3):373-7. [Medline].

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

  6. 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].

  7. 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].

  8. Ram-Wolff C, Martin-Garcia N, Bensussan A, Bagot M, Ortonne N. Histopathologic diagnosis of lymphomatous versus inflammatory erythroderma: a morphologic and phenotypic study on 47 skin biopsies. Am J Dermatopathol. Dec 2010;32(8):755-63. [Medline].

  9. 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].

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

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

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

  13. 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.

  14. 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.

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

  16. 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].

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

  18. 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].

  19. 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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Exfoliative dermatitis diffuse skin involvement.
Exfoliative dermatitis close-up view showing erythema and scaling.
Table. Drugs Implicated in the Causation of Exfoliative Dermatitis
ACE inhibitorsAllopurinolAminoglutethimideAmiodaroneAmitriptyline
AmoxicillinAmpicillinArsenicAspirinAtropine
AuranofinAurothioglucoseBarbituratesBenactyzineBeta-blockers
Beta caroteneBumetanideBupropionButabarbitalButalbital
CaptoprilCarbamazepineCarbidopaChloroquineChlorpromazine
ChlorpropamideCimetidineCiprofloxacinClofazimineClofibrate
Co-trimoxazoleCromolynCytarabineDapsoneDemeclocycline
DesipramineDiazepamDiclofenacDiflunisalDiltiazem
DoxorubicinDoxycyclineEnalaprilEtodolacFenoprofen
FluconazoleFluphenazineFlurbiprofenFurosemideGemfibrozil
GoldGriseofulvinHydroxychloroquineImipramineIndomethacin
IsoniazidIsosorbideKetoconazoleKetoprofenKetorolac
LithiumMeclofenamateMefenamic AcidMeprobamateMethylphenidate
MinocyclineNalidixic AcidNaproxenNifedipineNitrofurantoin
NitroglycerinNizatidineNorfloxacinOmeprazolePenicillamine
PenicillinPentobarbitalPerphenazinePhenobarbitalPhenothiazines
PhenylbutazonePhenytoinPiroxicamPrimidoneProchlorperazine
PropranololPyrazolonesQuinaprilQuinidineQuinine
RetinoidsRifampinStreptomycinSulfadoxineSulfamethoxazole
SulfasalazineSulfisoxazoleSulfonamidesSulfonylureasSulindac
TetracyclineTobramycinTrazodoneTrifluoperazineTrimethoprim
VancomycinVerapamil
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