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.

Physical Examination

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.

Complications

The most common complications of exfoliative dermatitis include dehydration, disturbed thermoregulation, poor nutritional status, and secondary bacterial infections (eg, skin and soft tissue infections). Secondary cutaneous infections may occur in patients with exfoliative dermatitis due to colonization of the skin with S aureus and impaired skin barrier function.

Use of corticosteroids or immunomodulators and impaired skin barrier function may result in opportunistic infections, including fungal infections.

Differential Diagnoses

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Exfoliative dermatitis diffuse skin involvement

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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)

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Author

David Vearrier, MD, MPH Professor of Emergency Medicine, Department of Emergency Medicine, University of Mississippi Medical Center

David Vearrier, MD, MPH is a member of the following medical societies: American Academy of Clinical Toxicology, 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 Program Director, Emergency Medicine, Einstein Medical Center Montgomery

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, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency Medicine

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