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.

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)

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.

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.

Treatment & Management

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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