Erythroderma

• Erythroderma

  • Intense and usually widespread reddening of the skin due to inflammatory skin disease
  • It often precedes or is associated with exfoliation (skin peeling off in scales or layers) - also known as exfoliative dermatitis
• Aetiology:

  • It is rare
  • Can arise at any age and in people of all races
  • 3 times more common in males
  • Most have a pre-existing skin disease or a systemic condition known to be associated with erythroderma
  • About 30% of cases are idiopathic
• Most commonly associated skin conditions:

  • Drug eruption - sulphonamides, isoniazid, penicillin
  • Dermatitis - especially atopic dermatitis
  • Psoriasis - especially after the withdrawal of systemic steroids
  • Pityriasis rubra pilaris
• Erythroderma may also be a sign of systemic disease:

  • Haematological malignancies e.g. lymphoma and leukaemia
  • Solid organ malignancies
  • Graft-versus-host disease
  • HIV infection
• By definition, generalised erythema and oedema or papulation affect 90% or more of the skin surface.
• Presentation:

  • Skin warm to the touch
  • Itch usually troublesome and sometimes intolerable - rubbing and scratching leads to lichenification
  • Eyelid swelling may result in ectropion
  • Scaling begins 2-6 days after the onset of erythema, as fine flakes or large sheets
  • Thick scaling may develop on the scalp with varying degrees of hair loss, including complete baldness
  • Palms and soles may become yellowing
  • nails become thickened and may shed
  • Generally swollen lymph nodes
• Systemic symptoms may be due to the erythroderma or to its cause.

  • Lymphadenopathy, hepatosplenomegaly, abnormal liver dysfunction and fever may suggest a drug hypersensitivity syndrome or malignancy.
  • Leg oedema may be due to inflamed skin, high output cardiac failure and/or hypoalbuminaemia.
• Complications:

  • Heat loss leads to hypothermia.
  • Fluid loss leads to electrolyte abnormalities and dehydration.
  • Red skin leads to high-output heart failure.
  • A secondary skin infection may occur (impetigo, cellulitis).
  • General unwellness can lead to pneumonia.
  • Hypoalbuminaemia from protein loss and increased metabolic rate causes oedema.
  • Longstanding erythroderma may result in pigmentary changes (brown and/or white skin patches).
• The following general measures apply:

  • Discontinue all unnecessary medications
  • Monitor fluid balance and body temperature
  • Maintain skin moisture with wet wraps, other types of wet dressings, emollients and mild topical steroids
  • Prescribe antibiotics for bacterial infection
  • Antihistamines may or may not be helpful for the itch.
• If a cause can be identified then specific treatment should be started, such as topical and systemic steroids for atopic dermatitis; acitretin or methotrexate for psoriasis.
• Erythroderma is potentially serious, even life-threatening, and the patient may require hospitalisation for monitoring and to restore fluid and electrolyte balance, circulatory status, and body temperature.