Chapter 162: Erythroderma

PATIENT STORY

A 34-year-old man presented with red skin from his neck to his feet for the last month (Figure 162-1). He was having a lot of itching, and his skin was shedding so that wherever he would sit, there would be a pile of skin that would remain. He denied fever and chills. He admitted to smoking and drinking heavily. The patient's vital signs were stable with normal blood pressure, and he preferred not to be hospitalized. He had some nail pitting but no personal or family history of psoriasis. The presumed diagnosis was erythrodermic psoriasis, but a punch biopsy was performed to confirm this. A complete blood count (CBC) and chemistry panel were ordered in anticipation of the patient requiring systemic medications. A purified protein derivative (PPD) was also placed at this time. The patient was then started on total body 0.1% triamcinolone under wet wrap overnight and given a follow-up appointment for the next day. The patient was also counseled to quit smoking and drinking. The following day his labs only revealed mild elevation in his liver function tests (LFTs). Two days following initial presentation, his PPD was negative and he was already feeling a bit better from the topical triamcinolone. Cyclosporine was promptly initiated, and the patient improved rapidly as a result.

INTRODUCTION

Erythroderma is an uncommon condition that affects all age groups. It is characterized by a generalized erythematous rash with associated scaling, affecting greater than 90% of the body's surface area. It is generally a manifestation of another underlying dermatosis or systemic disorder. It is associated with a range of morbidity and can have life-threatening metabolic and cardiovascular complications. Therapy is usually focused on treating the underlying disease, as well as addressing the systemic complications.

EPIDEMIOLOGY

Erythroderma is an uncommon condition that is generally a manifestation of underlying systemic or cutaneous disorders.

• It affects all age groups, from infants to the elderly.

• In adults, the average age of onset is 41 to 61 years of age, with a male-to-female ratio ranging from 2:1 to 4:1.¹

• It accounts for approximately 1% of all dermatologic hospital admissions.²

• It can be a very serious condition resulting in metabolic, infectious, cardiorespiratory, and thermoregulatory complications.³

• Mortality rate of 11.3 per 1000 patient years.⁴

ETIOLOGY AND PATHOPHYSIOLOGY

In almost 50% of cases, erythroderma occurs in the setting of a preexisting dermatosis; however, it may also occur secondary to underlying systemic disease, malignancy, and drug reactions. It is classified as idiopathic in 9% to 47% of cases.³

• The pathophysiology is not fully understood, but it ...