Exfoliative Dermatitis

Updated: Jun 22, 2021
  • Author: David Vearrier, MD, MPH; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
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Practice Essentials

Exfoliative dermatitis is characterized by generalized erythema with scaling or desquamation affecting at least 90% of the body surface area. Systemic derangements may occur with exfoliative dermatitis, including peripheral edema, increased insensible fluid losses, disturbed thermoregulation, and high-output heart failure. See Clinical Presentation for more detail.

Etiology of exfoliative dermatitis

The underlying etiology of exfoliative dermatitis is variable; the most common causes are as follows:

  • Psoriasis
  • Drug reactions
  • Atopic dermatitis
  • Cutaneous T-cell lymphoma

Exfoliative dermatitis is frequently idiopathic in nature. See Differential Diagnosis and Workup for more detail.

Treatment of exfoliative dermatitis

Treatment in the emergency department consists of the following:

  • Fluid resuscitation to replace insensible losses

  • Correction of electrolyte and thermoregulatory disturbances if present

  • Initiation of antihistamines and corticosteroids in consultation with a dermatologist

Patients with acute or severe exfoliative dermatitis may require hospitalization to correct and manage fluid and protein losses and electrolyte disturbances. See Treatment and Medication for more detail.



Exfoliative dermatitis, or erythroderma, is an erythematous, scaly dermatitis involving at least 90% of the skin surface. The diagnosis of exfoliative dermatitis is based on skin findings on physical examination and not on the underlying etiology for the dermatitis, which is variable and may be idiopathic (see Differential Diagnosis).

Exfoliative dermatitis diffuse skin involvement Exfoliative dermatitis diffuse skin involvement

The term "erythroderma" was first used by Hebra in 1868 to describe exfoliative dermatitis affecting at least 90% of the skin surface area. [1] Historically, exfoliative dermatitis was classified by its clinical course into one of three variants: Wilson-Brocq (chronic-relapsing), Hebra (chronic-persisting or progressive), and Savill (self-limited). These classifications are no longer used as clinical focus has shifted to the underlying etiology for the dermatitis.



The pathophysiologic processes resulting in exfoliative dermatitis vary with the underlying disorder responsible for the dermatitis. However, common to all conditions that cause exfoliative dermatitis is an increased rate of skin turnover. 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.

In exfoliative dermatitis, the number of cells in the germinative layer and their mitotic rate is increased. The transit time of cells through the epidermis is shortened. As a result, the exfoliated scales are incompletely keratinized and contain material normally retained by the skin, including proteins, amino acids, and nucleic acids, which may result in a negative nitrogen balance. [2, 3] The amount of scale lost varies by underlying condition and its severity. Exfoliative dermatitis due to drug reactions, eczema, and psoriasis may result in the loss of 7.2 g, 9.6 g, and 22.6 g of scale per day, respectively (normal range, 500-1000 mg). Protein lost in that scale is 4.2 g, 5.6 g, and 12.8 g per day, respectively. The decreased transit time also results in impaired skin barrier function from incomplete keratinization, which may increase the absorption of medications administered transcutaneously through damaged skin.

Another common pathophysiologic process to all forms of exfoliative erythroderma is increased blood flow to the skin, which, in combination with impaired skin barrier function, results in increased insensible fluid loss through transpiration. Dehydration and reflex tachycardia are common. In severe cases, high-output cardiac failure may occur. Increased cutaneous blood flow also leads to increased heat loss, which may lead to a compensatory hypermetabolism and cachexia. [1]


Etiology of Exfoliative Dermatitis

Within a large series of patients with exfoliative dermatitis, the underlying etiology was preexisting dermatitis (24%), psoriasis (20%), drug eruptions (19%), and cutaneous T-cell lymphoma (8%). [1] Within the category of preexisting dermatitis, the most common causes were atopic dermatitis (9%), contact dermatitis (6%), seborrheic dermatitis (4%), and chronic actinic dermatitis (3%). Despite investigation, 25% of exfoliative dermatitis is idiopathic in nature. Less common causes include ichthyoses, bullous dermatoses, pityriasis rubra pilaris, Ofuji papuloerythroderma, hypereosinophilic syndrome, [4] systemic lupus erythematosus.

Among infants, the major causes of exfoliative dermatitis are ichthyoses, immunodeficiencies, psoriasis, and infection (eg, staphylococcal scalded skin syndrome). [1]

Common and less common causes of exfoliative dermatitis in adults and clinical clues to diagnosis are included in Table 1. [5]  

Table 1. Clinical Clues to Causes of Exfoliative Dermatitis in Adults (Open Table in a new window)

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

Numerous drugs have been implicated in exfoliative dermatitis. Commonly and less commonly implicated medication are summarized in Table 2. [1]  

Table 2. Medications Associated With Exfoliative Dermatitis (Open Table in a new window)

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)



The incidence and prevalence of exfoliative dermatitis have not been well-characterized. [1]  


Exfoliative dermatitis occurs in all races. 


The male-to-female ratio is approximately 2:1 to 4:1.


The average age at onset is 52 years. [1] When children are excluded, the average age of onset in adults is 60 years. 



Prognosis depends on the underlying etiology causing the exfoliative dermatitis.

In general, long-term prognosis is good for patients with drug-induced disease after the offending agent is withdrawn and proper supportive measures are undertaken. Typically, symptoms resolve within 2-6 weeks after cessation of the offending agent.

For patients with idiopathic exfoliative dermatitis, the prognosis is poor. Frequent recurrences or chronic symptoms require long-term steroid therapy and its attendant sequelae.

For patients with underlying disease or malignancy, prognosis rests on the outcome and course of the disease process.


Patient Education

Patients should be educated on the risks of secondary bacterial infections (eg, skin and soft tissue infections), fluid loss and dehydration, and hyperthermia/hypothermia. Patients should be advised to avoid known or suspected etiologic agents (eg, medications, allergens). Educate patients with underlying disease about symptomatic treatment and advise that many cases spontaneously remit. Advise patients to drink plenty of fluids and follow a high-protein diet to counteract increased fluid and protein losses.