Erythroderma

Erythroderma is defined as the scaling erythematous dermatitis involving 90% or more of the cutaneous surface.
Also known as exfoliative dermatitis
Idiopathic exfoliative dermatitis – also known as the “red man syndrome”, is characterized by marked palmoplantar keratoderma, dermatopathic lymphadenopathy,increased IgE.
Increased skin perfusion leads to
Temperature dysregulation >
Resulting in skin loss and hypothermia >
High output state >
Cardiac failure
BMR raises to compensate for heat loss
Increased dehydration due to transpiration (similar to burns)
All lead to negative nitrogen balance and characterized by edema, hypoalbuminemia, loss of muscle mass.

1. ERYTHRODERMA Presenter – Dr. Deepak R. Chinagi Guide – Dr. L. S. Patil Shri B. M. Patil Medical College and Research Centre, Vijayapura 1

2. Introduction Erythroderma is defined as the scaling erythematous dermatitis involving 90% or more of the cutaneous surface. Also known as exfoliative dermatitis Idiopathic exfoliative dermatitis – also known as the “ red man syndrome ”, is characterized by marked palmoplantar keratoderma , dermatopathic lymphadenopathy,increased IgE . Shri B. M. Patil Medical College and Research Centre, Vijayapura 2

3. Shri B. M. Patil Medical College and Research Centre, Vijayapura 3

4. Pathophysiology Increased skin perfusion leads to Temperature dysregulation > Resulting in skin loss and hypothermia > High output state > Cardiac failure BMR raises to compensate for heat loss Increased dehydration due to transpiration (similar to burns) All lead to negative nitrogen balance and characterized by edema, hypoalbuminemia , loss of muscle mass. Shri B. M. Patil Medical College and Research Centre, Vijayapura 4

5. Normal skin loss per day is around 0.3 g/d Skin exfoliation may reach upto 20 – 30 g/d Excessive fluid loss through transpiration. 18 – 20 % mortality is seen. Male preponderance is seen .. Nearly 2-4 times.. Age ≥ 40 years Shri B. M. Patil Medical College and Research Centre, Vijayapura 5

6. Causes Causes Associated systemic conditions Atopic dermatitis Acute / Chronic Leukemia Contact dermatitis Reticulum cell carcinoma Dermatophytosis Carcinoma of rectum Hailey-Hailey Disease Carcinoma of fallopian tubes Leiner disease GVHD Lichen planus HIV Lupus eryhthematosus Lymphoma Mycosis Fungoides Multiple Myeloma Pemphigoid Carcinoma Lung Pitriyasis Rubra Pilaris Reiter Syndrome Psoriasis , Seborrheic Dermatitis Shri B. M. Patil Medical College and Research Centre, Vijayapura 6

7. Mnemonic Shri B. M. Patil Medical College and Research Centre, Vijayapura 7

8. Drugs that are commonly implicated in exfoliative dermatitis Shri B. M. Patil Medical College and Research Centre, Vijayapura 8

9. Clinical Features History of primary diease like psoriasis, atopic dermatitis may be present. Drug history has to elicited in detail, including OTC drugs Progression Rapid – Drug induced , lymphoma, leukemia, SSSS. Gradual – Psoriasis, Atopic Dermatitis. Pruritis is a predominant symptom Fever and Chills may occur. Shri B. M. Patil Medical College and Research Centre, Vijayapura 9

10. Clinical Features It often begns with generalized erythema . Scaling appears after 2-6 d. Scaling usually starts from flexural areas. Pruritis begins. Skin excoriations occur due to scratching. If it persists for weeks , hairs may shed, naiks may become ridged. Periorbital skin may be inflamed and edematous, result in ectropion . Shri B. M. Patil Medical College and Research Centre, Vijayapura 10

11. Clinical Features In Chronic cases , loss of pigment may occur with patchy/widespread. Similar to vitiligo . Dermatopathic lymphadenopathy can occur, Lymph node is enlarged and rubbery in consistency. Lymph node biopsy is advised. Shri B. M. Patil Medical College and Research Centre, Vijayapura 11

12. Diferential Diagnosis Acanthosis Nigricans Atopic Dermatitis Bullous Pemphigoid Allergic Contact Dermatitis Irritan Contact Dermatitis Cutaneous T cell Lymphoma Familial Benign Pemphigus (HH Disease) GVHD Lichen Planus Pemphigus Foilaceous Pitriyasis Rubra Pilaris Psoriasis – plaque Reactive arthritis Sarcoidosis Seborrheic Dermatitis Stasis Dermatitis Shri B. M. Patil Medical College and Research Centre, Vijayapura 12

13. Investigations CBC and LFT - ↑ESR, ↓ Hb , ↓ Sr.Albumin , ↑Sr. Globulin. IgE ↑ - Atopic dermatitis. Peripheral Blood Smears and bone marrow examinations. – leukemia workup Immunophentyping and flow cytometry – for lymphoma workup. Skin scraping , may show hyphae or scabies mites CD4 t cells are decreased in exfoliative dermatitis (in absence of HIV), studied by Griffiths et al. HIV test – PCR better than ELISA, Chest X ray done. Extensive work up for suspected cause. Shri B. M. Patil Medical College and Research Centre, Vijayapura 13

14. Investigations Patch test – for contact allergens and drugs that were used by patient prior to remission. Skin biopsy may show spongiotic dermatitis. Subacute / Chronic Dermatitis Shri B. M. Patil Medical College and Research Centre, Vijayapura 14

15. Treatment Strict Intake Output monitoring. Monitor BP and temperature , risk of hypotension and hypothermia. Maintain skn moisture, Avoid scratching, Avoid precipitating factors. Topical steroids. Treat underlying cause and complications. For psoriasis , Phototherapy and systemic medications are given. For idiopathic EF , prolonged glucocorticoids may be required , usually disease has multiple exacerbations . Avoid the causative Drug. Shri B. M. Patil Medical College and Research Centre, Vijayapura 15

16. Apply tap water gauze dressings. Change every 2-3 hrs. Topical steroids 0.025-0.5% triamcilone. Tepid bath once or twice /day As the condition improves , start on emolients . Antihistamines to decrease pruritis and provide sedation. Systemic Steroids provide some relief (avoided in psoriasis and SSSS) Proper Nutrition, to treat Hypoalbuminemia . Shri B. M. Patil Medical College and Research Centre, Vijayapura 16

17. Thank You Shri B. M. Patil Medical College and Research Centre, Vijayapura 17