eMedicine Specialties > Emergency Medicine > Dermatology
Dermatitis, Exfoliative
Updated: Jan 15, 2008
Introduction
Background
Exfoliative dermatitis, or erythroderma, is an erythematous, scaly dermatitis involving most, if not all, of the skin. This generalized scaling eruption of the skin is drug induced, idiopathic, or secondary to underlying cutaneous or systemic disease.
Appreciation for this condition requires an understanding of the skin's normal epithelial layer. Normal epidermis has a continual turnover of epithelial cells. Cell division occurs near the basal layer. As cells move toward the periphery, they become well keratinized. This process requires approximately 10-12 days. Cells subsequently remain in the stratum corneum for another 12-14 days prior to being sloughed off.
In exfoliative dermatitis, the mitotic rate in the basal layer increases and overall transit time decreases; therefore, more cells are lost from the surface. The mechanism responsible for this is not known, although an immunologic basis has been suggested.
Pathophysiology
Exfoliative dermatitis may occur in response to drug therapy, systemic disease, or an idiopathic entity. As many as 40% of cases involve preexisting cutaneous disease. Approximately 10% of cases are the result of drug reactions. As many as 40% are caused by underlying systemic disease. The remaining cases are idiopathic.
Histopathologic patterns observed for drug-induced and idiopathic causes of exfoliative dermatitis are nonspecific. Biopsy findings in individuals with preexisting cutaneous or systemic disease during an exfoliative stage may reveal, inconsistently, the underlying skin lesion or pathology. Through multiple-biopsy histologic analysis, the diagnosis may be confirmed in as many as 45% of patients.
Frequency
United States
An estimated 1% of hospitalizations are for skin disease.
International
The ratio of hospitalized patients experiencing adverse drug reactions is 3 in 1000. According to one large Finnish study, approximately 1% of these instances involve exfoliative dermatitis.
Mortality/Morbidity
The mortality rate approaches 30%. In a report of 108 patients with exfoliative dermatitis who were autopsied, 87 died from the underlying disease. No cause other than exfoliation was found for the remaining 17 patients.
Race
Exfoliative dermatitis occurs in all races. In the young black male population, research suggests exfoliative dermatitis may be a marker for HIV infection.
Sex
The male-to-female ratio is 2:1.
Age
Individuals older than 40 years are affected most frequently.
Clinical
History
- Prior dermatologic illnesses
- Treatment with new medications
- Underlying systemic diseases
- Swelling or adenopathy
- Recurrent infections
- Cough or change in bowel or urinary habits
- Constitutional symptoms of low-grade fever, chills, and malaise (more commonly, patients complain of skin erythema, tightness, and scaling)
Physical
- Gynecomastia is a common finding in almost all patients with exfoliative dermatitis of several weeks' duration; it is believed to be secondary to hyperestrogenism, but the precise mechanism is unknown.
- Additional findings include alopecia, dystrophic nails, and hypopigmentation and/or hyperpigmentation.
- More than 40% of patients were febrile, with temperatures higher than 38°C; a relative tachycardia also was noted.
- Firm, rubbery lymphadenopathy, referred to as dermatopathic lymphadenitis, is a common finding.
- Hepatomegaly was noted in more than 50% of patients in one series, and splenomegaly was noted in approximately 30% of patients, all of whom had lymphoma.
- Steatorrhea may develop and tends to resolve when exfoliative dermatitis clears.
- Patients with exfoliative dermatitis have increased cutaneous blood flow, transcutaneous fluid losses, and radiation and convective heat losses.
- A number of cases of hypothermia have been reported.
- Fluid shifts increase cardiac output, causing dyspnea, dependent edema, and cardiac failure (possibly) in some patients.
- Prostate or thyroid glands may be enlarged or nodular.
Causes
- Systemic diseases (10-40%)
- Lymphoma - Primarily cutaneous T-cell lymphoma (CTCL)
- Leukemia
- Multiple myeloma
- Carcinoma of the lung, prostate, colon, and thyroid
- Graft versus host disease
- Immunodeficiency, including HIV
- Hodgkin disease
- Cutaneous diseases (10-40%)
- Psoriasis
- Seborrheic dermatitis
- Atopic dermatitis
- Stasis dermatitis
- Contact dermatitis
- Pityriasis rubra pilaris
- Pemphigus foliaceus
- Mycosis fungoides
- Dermatophytosis
- Lichen planus
- Drugs (3-10%)
- Dimercaprol (British antilewisite [BAL])
- Codeine
- Captopril
- Diphenylhydantoin
- Gold
- Iodine
- Antimicrobials - Sulfas, penicillin (PCN), cephalosporins, minocycline, isoniazid
- Granulocyte colony-stimulating factor (GCSF)
- Phenytoin
- Allopurinol
- Mercury
- Arsenic
- Quinidine
- Barbiturates
- Trimethadione
- Aspirin
- Carbamazepine
- Idiopathic (15-45%)
More on Dermatitis, Exfoliative |
Overview: Dermatitis, Exfoliative |
| Differential Diagnoses & Workup: Dermatitis, Exfoliative |
| Treatment & Medication: Dermatitis, Exfoliative |
| Follow-up: Dermatitis, Exfoliative |
| References |
| Next Page » |
References
Abrahams I, McCarthy JT, Sanders SL. 101 cases of exfoliative dermatitis. Arch Dermatol. Jan 1963;87:96-101. [Medline].
Adams JE, Mali JW, Karger AG, eds. Exfoliative dermatitis (erythroderma). Curr Probl Dermatol. 1972;4.
Bolognia JL, Braverman IM. Skin manifestations of internal disease. In: Harrison's Principles of Internal Medicine. 14th ed. 1998:310-312.
Brady WJ, DeBehnke DJ. Generalized skin disorders. In: Emergency Medicine A Comprehensive Study Guide. 5th ed. 2000:1594-1603.
Freedberg I, Baden H. Dermatology in general medicine. In: Textbook and Atlas. Vol 1. 1987:502.
Karakayli G, Beckham G, Orengo I, Rosen T. Exfoliative dermatitis. Am Fam Physician. Feb 1 1999;59(3):625-30. [Medline].
McKenna JK, Leiferman KM. Dermatologic drug reactions. Immunol Allergy Clin North Am. Aug 2004;24(3):399-423, vi. [Medline].
Morar N, Dlova N, Gupta AK, Naidoo DK, Aboobaker J, Ramdial PK. Erythroderma: a comparison between HIV positive and negative patients. Int J Dermatol. Dec 1999;38(12):895-900. [Medline].
Moschella S, Hurley H. Dermatology. 2nd ed. 1985:543.
Nicolis GD, Helwig EB. Exfoliative dermatitis. A clinicopathologic study of 135 cases. Arch Dermatol. Dec 1973;108(6):788-97. [Medline].
Pruszkowski A, Bodemer C, Fraitag S, Teillac-Hamel D, Amoric JC, de Prost Y. Neonatal and infantile erythrodermas: a retrospective study of 51 patients. Arch Dermatol. Jul 2000;136(7):875-80. [Medline].
Querfeld C, Guitart J, Kuzel TM, Rosen S. Successful treatment of recalcitrant, erythroderma-associated pruritus with etanercept. Arch Dermatol. Dec 2004;140(12):1539-40. [Medline].
Quiceno GA, Cush JJ. Iatrogenic rheumatic syndromes in the elderly. Clin Geriatr Med. Aug 2005;21(3):577-88, vii. [Medline].
Rothe MJ, Bialy TL, Grant-Kels JM. Erythroderma. Dermatol Clin. Jul 2000;18(3):405-15. [Medline].
Shuster S, Brown JB. Gynaecomastia and urinary oestrogens in patients with generalised skin disease. Lancet. Dec 29 1962;2:1358. [Medline].
Sommer S, Henderson CA. Papuloerythroderma of Ofuji responding to treatment with cyclosporin. Clin Exp Dermatol. Jun 2000;25(4):293-5. [Medline].
Voigt GC, Kronthal HL, Crounse RG. Cardiac output in erythrodermic skin disease. Am Heart J. Nov 1966;72(5):615-20. [Medline].
Volcheck GW. Clinical evaluation and management of drug hypersensitivity. Immunol Allergy Clin North Am. Aug 2004;24(3):357-71, v. [Medline].
Wilson HT. Exfoliative dermatitis; its etiology and prognosis. AMA Arch Derm Syphilol. May 1954;69(5):577-88. [Medline].
Further Reading
Keywords
exfoliative dermatitis, erythroderma, epidermis, epithelial layer, epithelial cells, scaling eruption, scaly dermatitis
Overview: Dermatitis, Exfoliative