eMedicine Specialties > Dermatology > Papulosquamous Diseases

Erythroderma (Generalized Exfoliative Dermatitis): Treatment & Medication

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

Treatment

Medical Care

Patients presenting acutely with exfoliative dermatitis (ED) often require admission for inpatient management because their total body functions (including intake and output) can require monitoring. Hospital admission should be seriously considered in pediatric patients who present with erythroderma and fever because this presentation is a predictor of hypotension and even toxic shock syndrome. The principle of management is to maintain skin moisture, avoid scratching, avoid precipitating factors, apply topical steroids, and treat the underlying cause and complications. exfoliative dermatitis commonly resists therapy until the underlying disease is treated (eg, phototherapy, systemic medications in psoriasis). Outcome is unpredictable in idiopathic exfoliative dermatitis. The course is marked by multiple exacerbations, and prolonged glucocorticoid therapy often is needed.

  • Discontinue all unnecessary medications. Carefully monitor and control fluid intake, since patients can dehydrate or go into cardiac failure; monitor body temperature, since patients may become hypothermic.
  • Apply tap water–wet dressings (made from heavy mesh gauze); change every 2-3 hours. Apply intermediate-strength topical steroids (eg, triamcinolone cream 0.025-0.5%) beneath wet dressings. Suggest a tepid bath (may be comforting) once or more daily between dressing changes. Reduce frequency of dressings and gradually introduce emollients between dressing applications as exfoliative dermatitis improves.
  • Institute systemic antibiotics if signs of secondary infection are observed. Antihistamines help reduce pruritus and provide needed sedation.
  • Systemic steroids may be helpful in some cases but should be avoided in suspected cases of psoriasis and staphylococcal scalded skin syndrome.
  • Increased capillary permeability occasionally is severe enough to justify plasma infusion.
  • Preexisting malnutrition may become more marked and require nutritional intervention in older patients.

Consultations

Consult a dermatologist for all cases of exfoliative dermatitis.

Diet

Ensure adequate nutrition with emphasis on protein intake, since exfoliative dermatitis patients lose a lot of protein through excessive desquamation and show a tendency toward hypoalbuminemia. Alter diet as necessary if ingestion of a certain food group is suspected as the etiology of exfoliative dermatitis.

Activity

As tolerated

Medication

Topical steroids are the primary category of medications used to treat exfoliative dermatitis (ED). A sedative antihistamine may be a useful adjunct for pruritic patients, since it helps patients to sleep at night, thus limiting nocturnal scratching and excoriations. Antimicrobial agents often are used if an infection is suspected to be precipitating or complicating exfoliative dermatitis. Other drugs specifically indicated for management of underlying etiology of exfoliative dermatitis may be necessary.

Topical steroids

Exert anti-inflammatory effects by inhibiting early processes (eg, edema, fibrin deposition, capillary dilatation, movement of phagocytes into the area, phagocytic activities). In exfoliative dermatitis, they may inhibit the increased epidermal cell turnover that occurs. Indications include symptomatic relief of inflammation and/or pruritus associated with acute and chronic corticosteroid-responsive disorders.


Triamcinolone (Aristocort)

Medium-potency topical steroid. Use creams and lotions for moist weepy lesions and with intense inflammation (eg, exfoliative dermatitis). Frequency of use in exfoliative dermatitis depends on acute nature of disease and frequency with which wet dressings are changed.

Adult

Apply cream 0.025%, 0.1%, or 0.5% bid/qid
Apply lotion 0.025% or 0.1% bid/qid
Apply ointment 0.1% bid

Pediatric

Apply cream 0.025% qd/bid; 0.1% or 0.5% qd
Apply lotion 0.025% qd/bid; 0.1% qd
Apply ointment 0.1% qd/bid

Documented hypersensitivity; infections at treatment site or pre-existing skin atrophy

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Adrenal suppression, Cushing syndrome, intracranial hypertension, and growth retardation may occur as a result of systemic absorption of topical corticosteroids; children are more susceptible

Antihistamines

Exert both antipruritic and sedating effects. Used in treating histamine-mediated allergic reactions by competitively inhibiting H1 receptors on effector cells. To varying degrees, they exert sedative effects by crossing the blood-brain barrier and blocking central histaminogenic receptors.


Hydroxyzine (Atarax, Vistaril)

Antagonizes H1 receptors in periphery. May suppress histamine activity in subcortical region of CNS providing antipruritic effects

Adult

25-50 mg PO q4-6h prn

Pediatric

2-3 mg/kg/d PO divided tid/qid prn for pruritus (10 mg/5 mL syr)

May augment sedating effects of alcohol and other CNS depressants; may augment anticholinergic effects of anticholinergic drugs and drugs with anticholinergic effects

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Avoid in hepatic impairment except in exceptional conditions; ECG abnormalities may occur (eg, alteration of T waves); warn patients of expected increase in drowsiness and to avoid tasks requiring alertness or physical dexterity; may exacerbate crises in porphyric patients

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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