History
A thorough history may elucidate the underlying etiology for the exfoliative dermatitis. The most common cause of exfoliative dermatitis is generalization of a preexisting dermatitis. Therefore, patients should be queried about a history of psoriasis or atopic, contact, seborrheic, or chronic actinic dermatitis. Drug eruption is a common cause of exfoliative dermatitis, so a thorough medication history is essential. Drug-induced exfoliative dermatitis may occur with oral or topical medications. A history of a localized exanthem followed by generalization is more common with topical medications, while a history of a morbilliform or scarlatiniform eruption is common with oral medications.
The most common complaint in patients with exfoliative dermatitis aside from rash is pruritus, which occurs in approximately 90% of patients. [1] The severity of the pruritus varies by underlying condition, being most severe in atopic dermatitis and cutaneous T-cell lymphoma. Complaints of hair loss and nail changes are common. Sun exposure may worsen the rash, particularly in pityriasis rubra pilaris.
Physical
Vital sign derangements include tachycardia, hyperthermia, and hypothermia. Tachycardia is reflexive in nature, occurring from increased insensible fluid losses and third spacing of fluid. [1] Hyperthermia occurs in 37% of patients and may be due to a hypermetabolic state, while hypothermia occurs in 4% of patients and may be due to excessive heat loss from increased cutaneous blood flow.
Abdominal examination may reveal hepatomegaly (20%), which is most common in drug-induced exfoliative dermatitis. [1] Splenomegaly is uncommon and suggestive of lymphoma.
By virtue of the definition of exfoliative dermatitis, skin examination is significant for erythema and scaling of at least 90% of the skin area. In acute exfoliative dermatitis, erythema may precede exfoliation by 2-6 days and so may not be present when a patient first seeks medical attention. [1] The character of the scale may provide clues to the underlying etiology: fine in atopic dermatitis and dermatophytosis, greasy in seborrheic dermatitis, large exfoliative scale in drug eruptions, and crusted in pemphigus foliaceus.
In chronic exfoliative dermatitis, hyperpigmentation (45%), hypopigmentation or depigmentation (20%), palmoplantar keratoderma (30%), lichenification (one third), nonscarring alopecia (20%), and multiple seborrheic keratoses may be seen. [1] Nail changes may be present in 40% of patients and may include shininess, brittleness, dullness, discoloration, subungual hyperkeratosis, Beau lines, paronychia, splinter hemorrhages, and nail loss.
Pretibial or pedal edema may be seen in 50% of patients with exfoliative dermatitis. [1] Facial edema may occur with drug-induced exfoliative dermatitis. Diffuse lymphadenopathy is common, seen in approximately 50% of patients, and may be reactive in nature (ie, reactive dermatopathic lymphadenopathy) or may be due to lymphoma.
Causes
Within a large series of patients with exfoliative dermatitis, the underlying etiology was preexisting dermatitis (24%), psoriasis (20%), drug eruptions (19%), and cutaneous T-cell lymphoma (8%). [1] Within the category of preexisting dermatitis, the most common causes were atopic dermatitis (9%), contact dermatitis (6%), seborrheic dermatitis (4%), and chronic actinic dermatitis (3%). Despite investigation, 25% of exfoliative dermatitis is idiopathic in nature. Less common causes include ichthyoses, bullous dermatoses, pityriasis rubra pilaris, Ofuji papuloerythroderma, hypereosinophilic syndrome, [4] systemic lupus erythematosus.
Among infants, the major causes of exfoliative dermatitis are ichthyoses, immunodeficiencies, psoriasis, and infection (eg, staphylococcal scalded skin syndrome). [1]
Common and less common causes of exfoliative dermatitis in adults and clinical clues to diagnosis are included in Table 1. [5]
Table 1. Clinical Clues to Causes of Exfoliative Dermatitis in Adults (Open Table in a new window)
| Underlying Disease | History | Examination |
|---|---|---|
|
Psoriasis (common)
|
|
|
| Atopic dermatitis (common) |
|
|
| Drug reactions (common) |
|
|
| Idiopathic (common) |
|
|
|
Cutaneous T-cell lymphoma
(less common) |
|
|
|
Pityriasis rubra pilaris
(less common) |
|
|
|
Contact and stasis dermatitis with autosensitization
(less common) |
|
|
|
Paraneoplastic erythroderma
(less common) |
|
|
Numerous drugs have been implicated in exfoliative dermatitis. Commonly and less commonly implicated medication are summarized in Table 2. [1]
Table 2. Medications Associated With Exfoliative Dermatitis (Open Table in a new window)
| Common | Uncommon |
|---|---|
|
|
-
Exfoliative dermatitis diffuse skin involvement
Tables
| Underlying Disease | History | Examination |
|---|---|---|
|
Psoriasis (common)
|
|
|
| Atopic dermatitis (common) |
|
|
| Drug reactions (common) |
|
|
| Idiopathic (common) |
|
|
|
Cutaneous T-cell lymphoma
(less common) |
|
|
|
Pityriasis rubra pilaris
(less common) |
|
|
|
Contact and stasis dermatitis with autosensitization
(less common) |
|
|
|
Paraneoplastic erythroderma
(less common) |
|
|
| Common | Uncommon |
|---|---|
|
|
