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Erythroderma (Generalized Exfoliative Dermatitis)

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


Exfoliative dermatitis (ED) is a definitive term that refers to a scaling erythematous dermatitis involving 90% or more of the cutaneous surface. Exfoliative dermatitis is characterized by erythema and scaling involving the skin's surface and often obscures the primary lesions that are important clues to understanding the evolution of the disease. Clinicians are challenged to find the cause of exfoliative dermatitis by eliciting the history of illness prior to erythema and scaling, by probing with biopsies, and by performing blood studies. See the images below.

Exfoliative dermatitis diffuse skin involvement. Exfoliative dermatitis diffuse skin involvement.
Exfoliative dermatitis close-up view showing eryth Exfoliative dermatitis close-up view showing erythema and scaling.

The term red man syndrome is reserved for idiopathic exfoliative dermatitis, in which no primary cause can be found, despite serial examinations and tests. Idiopathic exfoliative dermatitis is characterized by marked palmoplantar keratoderma, dermatopathic lymphadenopathy, and a raised level of serum immunoglobulin E (IgE) and is more likely to persist than other types.

The term l'homme rouge refers to exfoliative dermatitis that is secondary to cutaneous T-cell lymphoma. The historic classification of exfoliative dermatitis into Wilson-Brocq (a chronic process associated with exacerbation and remissions), Hebra or pityriasis rubra (relentlessly progressive disease), and Savill (self-limiting) types lacks any clinical significance.



An increased skin blood perfusion occurs in exfoliative dermatitis (ED) that results in temperature dysregulation (resulting in heat loss and hypothermia) and possible high-output cardiac failure. The basal metabolic rate rises to compensate for the resultant heat loss. Fluid loss by transpiration is increased in proportion to the basal metabolic rate. The situation is similar to that observed in patients following burns (negative nitrogen balance characterized by edema, hypoalbuminemia, loss of muscle mass).

A marked loss of exfoliated scales occurs that may reach 20-30 g/d. This contributes to the hypoalbuminemia commonly observed in exfoliative dermatitis. Hypoalbuminemia results, in part, from decreased synthesis or increased metabolism of albumin. Edema is a frequent finding, probably resulting from fluid shift into the extracellular spaces. Immune responses may be altered, as evidenced by increased gamma-globulins, increased serum IgE in some cases, eosinophil infiltration, and CD4+ T-cell lymphocytopenia in the absence of HIV infection. Oxidative stress is also associated with drug-induced erythroderma.[1]




No racial predilection is reported for exfoliative dermatitis (ED).


Male-to-female ratio is 2-4:1.


Exfoliative dermatitis onset usually occurs in persons older than 40 years, except when the condition results from atopic dermatitis, seborrheic dermatitis, staphylococcal scalded skin syndrome, or a hereditary ichthyosis. Age of onset primarily is related to etiology.[2, 3]

Contributor Information and Disclosures

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.


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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