Erythroderma (Generalized Exfoliative Dermatitis) Workup

Updated: Jun 04, 2018
  • Author: Sanusi H Umar, MD, FAAD; Chief Editor: Dirk M Elston, MD  more...
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Workup

Laboratory Studies

Increased erythrocyte sedimentation rate, anemia, hypoalbuminemia, and hyperglobulinemia are frequent findings.

Byer and Bachur [39]  report that the levels of glucose, calcium, and creatinine and the platelet and polymorphonuclear leukocyte counts are of prognostic significance in children who present with erythroderma and fever.

A clinical diagnosis is made for psoriasis, as there is no consensus on diagnostic criteria and tests.

Increased IgE may be observed in exfoliative dermatitis (ED) when caused by atopic dermatitis.

Peripheral blood smears and bone marrow examination may be useful in a leukemia workup.

Immunophenotyping, flow cytometry, and particularly, B- and T-cell gene rearrangement analysis may be helpful in confirming the diagnosis if lymphoma is strongly suspected. High-scatter T cells are a biomarker for cutaneous T-cell lymphoma, [40]  and high throughput T-cell receptor sequencing is helpful for diagnosis. [41]

Skin scrapings may reveal hyphae or scabies mites.

Cultures may show bacterial overgrowth or the herpes simplex virus.

Perform HIV testing in the right setting; use polymerase chain reaction for viral detection, rather than enzyme-linked immunoassay, since exfoliative dermatitis has been reported to predict seroconversion in HIV infection. CD8 T-cell infiltration of the skin has been observed in patients with HIV infection and severe erythroderma. [42]

In a report by Griffiths et al, [43] decreased CD4+ T-cell count was observed in patients with exfoliative dermatitis in the absence of HIV disease.

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Imaging Studies

Pursue further tests (eg, positron emission tomography, computed tomography scanning, magnetic resonance imaging, chest radiography, mammography) if the clinical features so indicate. Fluorescence diagnosis can be helpful in assessing the response to therapy in patients with mycosis fungoides. [44]

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Other Tests

If the cause of exfoliative dermatitis (ED) is in doubt, survey patients for occult tumors or cancers. Perform chest radiography and routine cancer screenings appropriate for age and sex (eg, mammogram, stool occult blood test, sigmoidoscopy, prostate examination, serum prostate specific antigen level, cervical smear).

Patch testing can be performed to unveil contact allergens but should be performed only during periods of remission. In the patch test, include systemic drugs the patient was taking prior to the onset of exfoliative dermatitis.

Direct immunofluorescence studies diagnosed at least two reported cases of pemphigoid erythroderma, according to Scrivener et al. [45] TP53 mutations have been noted in Sézary syndrome and erythrodermic mycosis fungoides. [46]

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Procedures

Skin biopsies reveal nonspecific findings of spongiotic dermatitis; however, primary disease may be evident.

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Histologic Findings

The appearance of exfoliative dermatitis (ED) usually masks the underlying disease's specific histologic features. The most common histopathologic appearance is of either subacute or chronic dermatitis; however, biopsy is indicated, since diagnostic findings are present in 40-60% of cases.

[47]

A search for the underlying cause is necessary because of possible prognostic and therapeutic implications. Detailed histopathologic analysis with clinicopathologic correlation is mandatory in the remaining cases for which a specific cause is not apparent. Often, repeated biopsies and hematologic studies may be necessary to detect specific conditions (eg, cutaneous T-cell lymphoma).

[48]

Repeated biopsies have been reported to result in a diagnosis in 50% of cases that do not reveal specific findings initially.

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