Derm Dx: A red, scaly rash covering the entire body - Clinical Advisor

Derm Dx: A red, scaly rash covering the entire body

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A 45-year-old patient presents complaining of red and scaly rash covering her entire body. She reports the rashes that have come and gone during the past four months, but over the past week she has become completely red.

The patient is shivering slightly on exam, but otherwise appears nontoxic. Her trunk, extremities, and face are erythematous with a superficial desquamative scale. She complains of mild arthralgia, but states that she is otherwise healthy.

Erythroderma, also called exfoliative dermatitis, is a term that describes generalized redness of greater than 90% of the skin surface with associated scaling. Erythroderma is not a diagnosis per se; rather, it is a descriptive term.  Although as many as...

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Erythroderma, also called exfoliative dermatitis, is a term that describes generalized redness of greater than 90% of the skin surface with associated scaling. Erythroderma is not a diagnosis per se; rather, it is a descriptive term. 

Although as many as one-third of cases are idiopathic, the majority of patients with erythroderma have an underlying cutaneous or systemic disease that resulted in the erythrodermic state. Most commonly, erythroderma is a related to an underlying cutaneous disease, such as eczema or psoriasis, a drug reaction or cutaneous T-cell lymphoma. 

While it is quite simple to describe the patient as having “erythroderma,” it can be very challenging to find the underlying cause. Patients presenting with erythroderma require a comprehensive exam of the skin, hair and nails. For example when psoriasis is the underlying cause, there are typical nail changes, such as pitting of the nails that may be observed. 

Punch biopsies of the skin are frequently obtained. The histopathological findings of the underlying disease may be evident in up to two-thirds of biopsies. Repeat biopsies are sometimes required.

Erythroderma may be associated with extracutaneous manifestations such as lymphadenopathy, tachycardia, hyperthermia and edema. High output cardiac failure may result. In chronic cases, cachexia and anemia may be observed. 

Other cutaneous manifestations in chronic erythroderma include alopecia, dystrophy of the nails, ectropion and palmoplantar keratoderma. 

Management of erythroderma consists initially of managing any volume loss, ensuring adequate nutrition and treating any secondary infections. Secondly, an effort should be made towards determining the underlying cause of the erythroderma.  Treatment is targeted towards the underlying cause. 

For example, in erythrodermic psoriasis, the treatments may include treatments for severe psoriasis such as cyclosporine, acitretin and methotrexate.

If a drug is implicated, immediate cessation of the underlying drug is essential. In both drug reactions and idiopathic erythroderma, systemic corticosteroids may be used.  Topical corticosteroids may be an option, but this is often impractical given the very large body surface area affected. 

After extensive investigation it was determined that the cause of the erythroderma in the case of this patient was subacute cutaneous lupus erythematosus, which is a very uncommon cause of erythroderma. The patient’s eruption cleared with oral corticosteroids. 

Adam Rees, MD, is a graduate of the University of California Los Angeles School of Medicine and a resident in the Department of Dermatology at Baylor College of Medicine in Houston.

References

  1. Bolognia J, Jorizzo JL, Rapini RP. “Chapter 11: Erythroderma.” Dermatology. St. Louis: Mosby/Elsevier, 2008.
  2. James WD, Berger TD, Elston DM et al. “Chapter 11: Pityriasis Rosea, Pityriasis Rubra Pilaris, and Other Papulosquamous and Hyperkeratotic Diseases.” Andrews’ Diseases of the Skin: Clinical Dermatology. Philadelphia: Saunders Elsevier, 2006.

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