Erythroderma (Generalized Exfoliative Dermatitis) Clinical Presentation

Updated: Jun 03, 2018
  • Author: Sanusi H Umar, MD, FAAD; Chief Editor: Dirk M Elston, MD  more...
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Presentation

History

History is the most important aid in diagnosing exfoliative dermatitis (ED). [9] Patients may have a history of the primary disease (eg, psoriasis, atopic dermatitis). Elicit a comprehensive drug history, including over-the-counter drugs.

Disease usually evolves rapidly when it results from drug allergens, lymphoma, leukemia, or staphylococcal scalded skin syndrome. Disease evolution is more gradual when it results from psoriasis, atopic dermatitis, or the spread of primary disease.

Pruritus is a prominent and frequent symptom. Malaise, fever, and chills may occur.

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Physical Examination

Patients often present with generalized erythema. Scaling appears 2-6 days after the onset of erythema, usually starting from flexural areas. Pruritus commonly results in excoriations. When exfoliative dermatitis (ED) persists for weeks, hair may shed; nails may become ridged and thickened and also may shed. Periorbital skin may be inflamed and edematous, resulting in ectropion (with consequent epiphora).

In chronic cases, pigmentary disturbances can occur (especially in darker-skinned races); patchy or widespread loss of pigment (resembling vitiligo) has been reported.

Diligent search for residual signs of underlying disease occasionally yields dividends. Residual signs may include the following:

  • Islands of sparing in pityriasis rubra pilaris
  • Few typical psoriatic plaques in psoriasis
  • Eyelid lesion may be a presenting symptom of mycosis fungoides, a cause of exfoliative dermatitis [10]
  • Papules or oral lesions of lichen planus
  • Superficial blisters of pemphigus foliaceus
  • Erythematous papular lesions of an early drug eruption

Dermatopathic lymphadenopathy can occur in exfoliative dermatitis not caused by lymphoma or leukemia. A lymph node biopsy is advised when lymph nodes exhibit lymphomatous characteristics (eg, large size, rubbery consistency) and the cause of exfoliative dermatitis is undetermined.

The general picture is modified according to the nature of the underlying disease and the patient's general physical condition.

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Causes

Determining specific etiologies in exfoliative dermatitis (ED) often is not possible; however, it is necessary to attempt since etiology may impact disease course and management options. The list of conditions that can cause exfoliative dermatitis is extensive and continues to expand. Cutaneous diseases that cause exfoliative dermatitis and the systemic diseases associated with them include the following:

The most common causes of exfoliative dermatitis are best remembered by the mnemonic device ID-SCALP. The causes and their frequencies are as follows:

  • Idiopathic - 30%
  • Drug allergy - 28%
  • Seborrheic dermatitis - 2%
  • Contact dermatitis - 3%
  • Atopic dermatitis - 10%
  • Lymphoma and leukemia - 14%
  • Psoriasis - 8%

More than 135 drugs have been implicated in the causation of exfoliative dermatitis (see Table). In many cases of protracted exfoliative dermatitis classified as being of undetermined cause, careful follow-up care and reevaluation implicated atopic dermatitis in older patients, intake of drugs overlooked by the patient, and prelymphomatous eruption as causative factors. It should be noted that psoriasiform erythroderma has been induced by the tumor necrosis factor (TNF)–alpha inhibitor golimumab. [11]

Sarcoidosis-associated erythroderma may demonstrate lichenoid papules as a clue to the diagnosis. [12]

Table. Drugs Implicated in the Causation of Exfoliative Dermatitis (Open Table in a new window)

99mTC-sestamibi [13]

ACE inhibitors

Allopurinol

Aminoglutethimide

Amiodarone

Amitriptyline

Amoxicillin

Ampicillin

Angiogenetic inhibitors [14]

Arsenic

Aspirin

Atropine

Auranofin

Aurothioglucose

Barbiturates

Benactyzine

Beta-blockers

Beta carotene

Bumetanide

Bupropion

Butabarbital

Butalbital

Captopril

Carbamazepine

Carbidopa

Cephalosporins [15]

Chloroquine

Chlorpromazine

Chlorpropamide

Cimetidine

Ciprofloxacin

Cisplatin

Clofarabine [16]

Clofazimine

Clofibrate

Co-trimoxazole

Cromolyn

Cytarabine

Dapsone

Demeclocycline

Desipramine

Diazepam

Diclofenac

Diflunisal

Diltiazem

Doxorubicin

Doxycycline

Efavirenz [17]

Enalapril

Escitalopram [18]

Esomeprazole [19]

Ethambutol [20]

Etodolac

Fenofibrate [21]

Fenoprofen

Fluconazole

Fluindione [22]

Fluoxetine [23]

Fluphenazine

Flurbiprofen

Furosemide

Gemfibrozil

Gliclazide [24]

Glipizide [25]

Gold

Griseofulvin

Hydroxychloroquine

Imatinib [26]

Imipramine

Indomethacin

Intravenous immunoglobulin [27]

Intravesical mitomycin C [28]

Iodixanol [29]

Isoniazid

Isosorbide

Ketoconazole

Ketoprofen

Ketorolac

Leflunomide [30]

Lithium

Meclofenamate

Mefenamic Acid

Meprobamate

Methylphenidate

Midodrine [31]

Minocycline

Morphine sulfate [32]

Nalidixic Acid

Naproxen

Nevirapine [33]

Nitrazepam [25]

Nifedipine

Nitrofurantoin

Nitroglycerin

Nizatidine

Norfloxacin

Omeprazole

Pantoprazole [34]

Penicillamine

Penicillin

Pentobarbital

Perphenazine

Phenobarbital

Phenothiazines

Phenylbutazone

Phenytoin

Piroxicam

Primidone

Prochlorperazine

Propranolol

Pyrazinamide [20]

Pyrazolones

Quinapril

Quinidine

Quinine

Retinoids

Rifampin

Sorafenib [35]

Streptomycin

Strontium ranelate [36]

Sulfadoxine

Sulfamethoxazole

Sulfasalazine

Sulfisoxazole

Sulfonamides

Sulfonylureas

Sulindac

Terbinafine [37]

Tetracycline

Tobramycin

Tocilizumab [38]

Trazodone

Trifluoperazine

Trimethoprim

Vancomycin

Verapamil

Warfarin [39]

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Complications

Complications in exfoliative dermatitis (ED) depend on underlying disease. Secondary infection, dehydration, electrolyte imbalance, temperature dysregulation, and high-output cardiac failure are potential complications in all cases.

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