Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Exfoliative Dermatitis Clinical Presentation

  • Author: David Vearrier, MD, MPH; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
 
Updated: Apr 11, 2016
 

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.

 

Next

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.

 

Previous
Next

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)



 



  • Medical history or family history of psoriasis
  • Withdrawal of corticosteroids, methotrexate, or cyclosporine
  • Face is spared
  • Nail pitting, translucent yellow-red nailbed discoloration, onycholysis
  • Inflammatory arthritis
Atopic dermatitis (common)
  • Past medical history or family history of atopy such as eczema, allergic rhinitis, or asthma
  • Severe pruritus
  • Cataracts
  • Flexural skin most severely affected
  • Lichenification
  • Prurigo nodularis
Drug reactions (common)
  • Recent history of morbilliform or scarlatiniform exanthem
  • No past history of skin disease
  • Medication history includes one of implicated drugs
  • Facial edema
  • Purpura in dependent areas
Idiopathic (common)
  • Elderly men
  • Severe pruritus
  • Chronic and relapsing
  • Palmoplantar keratoderma
  • Dermatopathic lymphadenopathy
Cutaneous T-cell lymphoma



(less common)



  • Intense pruritus
  • Reddish-purple hue
  • Painful, fissured keratoderma
  • Alopecia
  • Leonine facies
Pityriasis rubra pilaris 



(less common)



  • Exacerbated by sun exposure
  • Cephalocaudal progression
  • Salmon hue
  • Sharply demarcated islands of sparing ("nappes claires")
  • Waxy keratoderma
  • Perifollicular keratotic papules
Contact and stasis dermatitis with autosensitization



(less common)



  • History of localized rash
  • Distribution of initial lesions
  • Occupational exposures, hobbies
  • Oral medications (systemic contact dermatitis)
 
Paraneoplastic erythroderma 



(less common)



  • History of malignancy or lymphoproliferative disorder
  • Fine scale
  • Hyperpigmentation
  • Cachexia

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
  • Allopurinol
  • Beta-lactam antibiotics
  • Carbamazepine
  • Gold
  • Phenobarbital
  • Phenytoin
  • Sulfasalazine
  • Sulfonamides
  • Zalcitabine
  • ACE-inhibitors
  • Chloroquine
  • Colony-stimulating factors
  • Cytarabine
  • Dapsone
  • Diflunisal
  • Efavirenz [6]
  • Fluindione
  • Hydroxychloroquine
  • Isoniazid
  • Isotretinoin [7]
  • Lithium
  • Minocycline
  • Platinum-based antineoplastics
  • Proton-pump inhibitors
  • Ribavirin
  • Thalidomide
  • Tocilizumab [8]
  • Vancomycin (not "red man syndrome" during infusion)
   
   

 

Previous
 
 
Contributor Information and Disclosures
Author

David Vearrier, MD, MPH Assistant Professor, Division of Medical Toxicology, Department of Emergency Medicine, Drexel University College of Medicine

David Vearrier, MD, MPH is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Medical Toxicology, American College of Occupational and Environmental Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director for Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency Medicine, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians

Disclosure: Nothing to disclose.

Additional Contributors

Mark Louden, MD Assistant Professor of Clinical Medicine, Division of Emergency Medicine, Department of Medicine, University of Miami, Leonard M Miller School of Medicine

Mark Louden, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Mark P Eid, MD Founder and Director, Virginia Dermatology and Skin Surgery Center

Mark P Eid, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, Pennsylvania Academy of Dermatology

Disclosure: Nothing to disclose.

Mary V Kaldas, MD Resident Physician in Anatomic Pathology, National Institutes of Health

Disclosure: Nothing to disclose.

Acknowledgements

Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director for Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Mark W Fourre, MD Program Director, Department of Emergency Medicine, Maine Medical Center; Associate Clinical Professor, Department of Surgery, University of Vermont School of Medicine

Disclosure: Nothing to disclose.

Therese I McBride, DO Assistant Professor, Department of Emergency Medicine, University of Arkansas for Medical Sciences

Therese I McBride, DO is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and American Medical Association

Disclosure: Nothing to disclose.

Therese I Mendenhall, DO  Resident Physician, Department of Emergency Medicine, University of Arkansas for Medical Sciences College of Medicine

Disclosure: Nothing to disclose.

Jonathan R Pilcher, MD  Resident Physician, Department of Emergency Medicine, University of Arkansas for Medical Sciences College of Medicine

Disclosure: Nothing to disclose.

Selwyn Waterton, MD Assistant Professor, Department of Emergency Medicine, State University of New York Downstate Health Sciences Center

Disclosure: Nothing to disclose.

References
  1. Sterry W, Steinhoff M. Erythroderma. Bolognia JL, Jorizzo JL, Schaffer JV, eds. Dermatology. 3rd ed. Elsevier Limited; 2012. 171-81.

  2. Salami TA, Enahoro Oziegbe O, Omeife H. Exfoliative dermatitis: patterns of clinical presentation in a tropical rural and suburban dermatology practice in Nigeria. Int J Dermatol. 2012 Sep. 51(9):1086-9. [Medline].

  3. Kanthraj GR, Srinivas CR, Devi PU, Ganasoundari A, Shenoi SD, Deshmukh RP, et al. Quantitative estimation and recommendations for supplementation of protein lost through scaling in exfoliative dermatitis. Int J Dermatol. 1999 Feb. 38 (2):91-5. [Medline].

  4. Mahajan VK, Singh R, Mehta KS, Chauhan PS, Sharma S, Gupta M, et al. Idiopathic hypereosinophilic syndrome: a rare cause of erythroderma. J Dermatol Case Rep. 2014 Dec 31. 8 (4):108-14. [Medline].

  5. Bolognia JL, Schaffer JV, Duncan KO, Ko CJ. Erythroderma. Dermatology Essentials. Philadelphia, Pa: Elsevier Saunders; 2014. 76-83.

  6. Zhang JC, Sun YT. Efavirenz-induced exfoliative dermatitis. Scand J Infect Dis. 2012 Jun 20. [Medline].

  7. Ipek Y, Hulya D, Melih A. Disseminated exfoliative dermatitis associated with all-transretinoic Acid in the treatment of acute promyelocytic leukemia. Case Report Med. 2012. 2012:236174. [Medline]. [Full Text].

  8. Brănişteanu DE, Voicu CM, Creţu A, Dimitriu A, Luca MC, Sălăvăstru CM. Adverse reactions of biological therapy for psoriasis. Rev Med Chir Soc Med Nat Iasi. 2015 Jan-Mar. 119 (1):38-44. [Medline].

  9. Shim TN, Berth-Jones J. Erythroderma. Lebwohl MG, Heymann WR, Berth-Jones J, Coulson I, eds. Treatment of Skin Disease: Comprehensive Therapeutic Strategies. 4th ed. Philadelphia, Pa: Elsevier Saunders; 2013. 234-38.

  10. Sommer S, Henderson CA. Papuloerythroderma of Ofuji responding to treatment with cyclosporin. Clin Exp Dermatol. 2000 Jun. 25(4):293-5. [Medline].

  11. Querfeld C, Guitart J, Kuzel TM, Rosen S. Successful treatment of recalcitrant, erythroderma-associated pruritus with etanercept. Arch Dermatol. 2004 Dec. 140(12):1539-40. [Medline].

 
Previous
Next
 
Exfoliative dermatitis diffuse skin involvement
Table 1. Clinical Clues to Causes of Exfoliative Dermatitis in Adults
Underlying Disease History Examination
Psoriasis (common)



 



  • Medical history or family history of psoriasis
  • Withdrawal of corticosteroids, methotrexate, or cyclosporine
  • Face is spared
  • Nail pitting, translucent yellow-red nailbed discoloration, onycholysis
  • Inflammatory arthritis
Atopic dermatitis (common)
  • Past medical history or family history of atopy such as eczema, allergic rhinitis, or asthma
  • Severe pruritus
  • Cataracts
  • Flexural skin most severely affected
  • Lichenification
  • Prurigo nodularis
Drug reactions (common)
  • Recent history of morbilliform or scarlatiniform exanthem
  • No past history of skin disease
  • Medication history includes one of implicated drugs
  • Facial edema
  • Purpura in dependent areas
Idiopathic (common)
  • Elderly men
  • Severe pruritus
  • Chronic and relapsing
  • Palmoplantar keratoderma
  • Dermatopathic lymphadenopathy
Cutaneous T-cell lymphoma



(less common)



  • Intense pruritus
  • Reddish-purple hue
  • Painful, fissured keratoderma
  • Alopecia
  • Leonine facies
Pityriasis rubra pilaris 



(less common)



  • Exacerbated by sun exposure
  • Cephalocaudal progression
  • Salmon hue
  • Sharply demarcated islands of sparing ("nappes claires")
  • Waxy keratoderma
  • Perifollicular keratotic papules
Contact and stasis dermatitis with autosensitization



(less common)



  • History of localized rash
  • Distribution of initial lesions
  • Occupational exposures, hobbies
  • Oral medications (systemic contact dermatitis)
 
Paraneoplastic erythroderma 



(less common)



  • History of malignancy or lymphoproliferative disorder
  • Fine scale
  • Hyperpigmentation
  • Cachexia
Table 2. Medications Associated With Exfoliative Dermatitis
Common Uncommon
  • Allopurinol
  • Beta-lactam antibiotics
  • Carbamazepine
  • Gold
  • Phenobarbital
  • Phenytoin
  • Sulfasalazine
  • Sulfonamides
  • Zalcitabine
  • ACE-inhibitors
  • Chloroquine
  • Colony-stimulating factors
  • Cytarabine
  • Dapsone
  • Diflunisal
  • Efavirenz [6]
  • Fluindione
  • Hydroxychloroquine
  • Isoniazid
  • Isotretinoin [7]
  • Lithium
  • Minocycline
  • Platinum-based antineoplastics
  • Proton-pump inhibitors
  • Ribavirin
  • Thalidomide
  • Tocilizumab [8]
  • Vancomycin (not "red man syndrome" during infusion)
   
   
Previous
Next
 
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.