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Erythroderma (Generalized Exfoliative Dermatitis) Follow-up

  • Author: Sanusi H Umar, MD, FAAD; Chief Editor: Dirk M Elston, MD  more...
 
Updated: Mar 03, 2016
 

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[63] ), 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[64] ), and that methotrexate is associated with many adverse effects, including toxicities of the liver, lungs, and bone marrow.

In addition to their high cost, the widespread use of biologics has been deterred by fear of an increased risk of new or recurrent malignancies in patients with psoriasis, although no recent evidence supports this claim.[65]  However tumor necrosis factor-alpha inhibitors and monoclonal antibodies can cause the formation of antidrug antibodies (ADAs) that affect the clinical response, with ADAs reported in 0-44.8% of patients.[66]

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Inpatient & Outpatient Medications

Appropriate in/outpatient medications are influenced by the underlying etiology of exfoliative dermatitis (ED). For example, prednisone may be contraindicated in exfoliative dermatitis secondary to psoriasis, while retinoids are an excellent choice for this disease. In patients with mycosis fungoides, who receive a differential diagnosis of psoriasis, special attention must be made prior to prescribing tumor necrosis factor-alpha inhibitors, given that they might cause mycosis fungoides to progress.[67]

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Transfer

Transfer patients with exfoliative dermatitis (ED) to the care of a dermatologist.

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Deterrence/Prevention

Prevention of exfoliative dermatitis (ED) 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 (ED) 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 study35 of pediatric patients (aged <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.

Mortality varies according to the disease's cause. In a study of 91 of 102 patients with exfoliative dermatitis by Sigurdsson et al,[68] a mortality rate of 43% was observed. Only 18% of the deaths were directly related to exfoliative dermatitis. In 74% of the deaths, causes unrelated to exfoliative dermatitis were implicated.

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Patient Education

Educate patients on the specifics of the underlying cause of their exfoliative dermatitis (ED) and the importance of diligent follow-up management as indicated. Patients should be educated on the benefits of a healthy lifestyle and to immediately treat occurrences of erythroderma to better manage their diseases in the long term. Patients should be advised to avoid the use of and/or contact with of irritant soaps, lotions, detergents, and chlorine, and special considerations should be made for allergies, especially for patients with atopic dermatitis.[62]  Excessive sweating should also be avoided.

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Contributor Information and Disclosures
Author

Sanusi H Umar, MD, FAAD Clinical Instructor of Medicine, Department of Medicine, Division of Dermatology, University of California, Los Angeles, David Geffen School of Medicine

Sanusi H Umar, MD, FAAD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, 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 Medical Association, American Society for Dermatologic Surgery, National Medical Association, Pacific Dermatologic Association

Disclosure: Nothing to disclose.

Specialty Editor Board

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, Texas Medical Association, Association of Military Dermatologists, Texas Dermatological Society

Disclosure: Nothing to disclose.

Rosalie Elenitsas, MD Herman Beerman 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, American Medical Association, American Society of Dermatopathology, Pennsylvania Academy of Dermatology

Disclosure: Received royalty from Lippincott Williams Wilkins for textbook editor.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

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

Disclosure: Nothing to disclose.

Additional Contributors

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, United States and Canadian Academy of Pathology

Disclosure: Nothing to disclose.

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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
99mTC-sestamibi[8] ACE inhibitors Allopurinol Aminoglutethimide Amiodarone
Amitriptyline Amoxicillin Ampicillin Angiogenetic inhibitors[9] Arsenic
Aspirin Atropine Auranofin Aurothioglucose Barbiturates
Benactyzine Beta-blockers Beta carotene Bumetanide Bupropion
Butabarbital Butalbital Captopril Carbamazepine Carbidopa
Cephalosporins[10] Chloroquine Chlorpromazine Chlorpropamide Cimetidine
Ciprofloxacin Cisplatin Clofarabine[11] Clofazimine Clofibrate
Co-trimoxazole Cromolyn Cytarabine Dapsone Demeclocycline
Desipramine Diazepam Diclofenac Diflunisal Diltiazem
Doxorubicin Doxycycline Efavirenz[12] Enalapril Escitalopram[13]
Esomeprazole[14] Ethambutol[15] Etodolac Fenofibrate[16] Fenoprofen
Fluconazole Fluindione[17] Fluoxetine[18] Fluphenazine Flurbiprofen
Furosemide Gemfibrozil Gliclazide[19] Glipizide[20] Gold
Griseofulvin Hydroxychloroquine Imatinib[21] Imipramine Indomethacin
Intravenous immunoglobulin[22] Intravesical mitomycin C[23] Iodixanol[24] Isoniazid Isosorbide
Ketoconazole Ketoprofen Ketorolac Leflunomide[25] Lithium
Meclofenamate Mefenamic Acid Meprobamate Methylphenidate
Midodrine[26] Minocycline Morphine sulfate[27] Nalidixic Acid Naproxen
Nevirapine[28] Nitrazepam[20] Nifedipine Nitrofurantoin Nitroglycerin
Nizatidine Norfloxacin Omeprazole Pantoprazole[29] Penicillamine
Penicillin Pentobarbital Perphenazine Phenobarbital Phenothiazines
Phenylbutazone Phenytoin Piroxicam Primidone Prochlorperazine
Propranolol Pyrazinamide[15] Pyrazolones Quinapril Quinidine
Quinine Retinoids Rifampin Sorafenib[30] Streptomycin
Strontium ranelate[31] Sulfadoxine Sulfamethoxazole Sulfasalazine Sulfisoxazole
Sulfonamides Sulfonylureas Sulindac Terbinafine[32] Tetracycline
Tobramycin Tocilizumab[33] Trazodone Trifluoperazine Trimethoprim
Vancomycin Verapamil Warfarin[34]
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