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Exfoliative Dermatitis Workup

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

Approach Considerations

The primary emergency department role in the workup of exfoliative dermatitis is evaluation for systemic derangements as a result of increased insensible fluid loses, changes in fluid distribution, and disturbed thermoregulation. While the underlying cause of some cases of exfoliative dermatitis (eg, drug-induced or generalization of a preexisting dermatitis) may be presumptively identified in the emergency department, identification and/or confirmation of the underlying condition is typically beyond the scope of emergency department care. Therefore, appropriate follow up with a dermatologist for further testing such as skin biopsy and/or lymph node biopsy is critical.

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Laboratory Studies

Laboratory studies that may be performed from the emergency department include the following:

  • Complete blood count: May demonstrate iron-deficiency anemia or anemia of chronic disease; eosinophilia may be present in cases due to generalization of atopic dermatitis; eosinophilia should also prompt consideration of DRESS (drug rash with eosinophilia and systemic symptoms)/DIHS (drug-induced hypersensitivity) in the differential diagnosis
  • Chemistry panel: May demonstrate hypernatremia, prerenal azotemia, or acute renal failure due to insensible fluid losses
  • Serum albumin and prealbumin: May be decreased owing to poor nutritional status from protein loss through exfoliation
  • Erythrocyte sedimentation rate and serum quantitative C-reactive protein: May demonstrate systemic inflammatory state
  • Urinalysis, blood cultures: May be obtained if there is suspicion of infection as a cause of exacerbation of preexisting skin disease (eg, generalization of psoriasis)
  • Nasal swab for methicillin-resistant Staphylococcus aureus (MRSA)

 

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Imaging Studies

In most cases, imaging is not necessary. Chest radiograph and other imaging may obtained if there is suspicion of infection as a cause of exacerbation of preexisting skin disease (eg, generalization of psoriasis) or if high-output cardiac failure is suspected.

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Procedures

No procedures are typically necessary in the emergency department evaluation of exfoliative dermatitis. Peripheral intravenous access by nursing may be difficult to obtain because of overlying skin changes, and ultrasound-guided venous access may be necessary. Inpatient or outpatient follow-up procedures include skin biopsy, which may give histologic clues to the underlying disease. In patients with diffuse lymphadenopathy, follow up includes lymph node biopsy with flow cytometry.

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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].

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Exfoliative dermatitis diffuse skin involvement
Table 1. Clinical Clues to Causes of Exfoliative Dermatitis in Adults
Underlying DiseaseHistoryExamination
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
CommonUncommon
  • 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)
  
  
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