Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT PART 6-17: EXFOLIATIVE DERMATITIS + Key Features Download Section PDF Listen +++ +++ Essentials of Diagnosis ++ Scaling and erythema over most of the body Itching, malaise, fever, chills, weight loss +++ General Considerations ++ A preexisting dermatosis is the cause in up to two-thirds of cases, including Psoriasis Atopic dermatitis Contact dermatitis Pityriasis rubra pilaris Seborrheic dermatitis Other causes Reactions to topical or systemic drugs (accounts for about 15% of cases) Cancer (paraneoplastic symptom of lymphoma, solid tumors and, most commonly, cutaneous T cell lymphoma) accounts for 10% Idiopathic in ~10% At the time of acute presentation, without a clear-cut prior history of skin disease or drug exposure, it may be impossible to make a specific diagnosis of the underlying condition, and diagnosis may require continued observation +++ Etiology ++ Idiopathic Drug eruption (eg, proton pump inhibitors, nevirapine) Seborrheic dermatitis Contact dermatitis Atopic dermatitis Psoriasis Cancer (Sézary syndrome of cutaneous T cell lymphoma, Hodgkin disease) Pityriasis rubra pilaris + Clinical Findings Download Section PDF Listen +++ +++ Symptoms and Signs ++ Symptoms may include itching, weakness, malaise, fever, and weight loss Chills are prominent Redness and scaling is widespread Loss of hair and nails can occur Generalized lymphadenopathy may be due to lymphoma or leukemia or may be reactive The mucosae are spared +++ Differential Diagnosis ++ Psoriasis Seborrheic dermatitis Drug eruption Toxic shock syndrome (staphylococcal or streptococcal) Scarlet fever Staphylococcal scalded skin syndrome Erythema multiforme or toxic epidermal necrolysis + Diagnosis Download Section PDF Listen +++ +++ Laboratory Tests ++ Peripheral leukocytes may show clonal rearrangements of the T cell receptor in Sézary syndrome +++ Diagnostic Procedures ++ A skin biopsy is required and may show changes of a specific inflammatory dermatitis or an underlying cutaneous T cell lymphoma or Sézary syndrome + Treatment Download Section PDF Listen +++ +++ Medications ++ See Table 6–2 Stop all drugs, if possible Systemic corticosteroids may provide remarkable improvement in severe or fulminant exfoliative dermatitis, but long-term therapy should be avoided For cases of psoriatic erythroderma and pityriasis rubra pilaris, either acitretin, methotrexate, cyclosporine, or a tumor necrosis factor (TNF) inhibitor may be indicated Erythroderma secondary to lymphoma or Sézary syndrome requires specific topical or systemic chemotherapy Suitable antibiotic drugs with coverage for Staphylococcus should be given when there is evidence of bacterial infection +++ Therapeutic Procedures ++ Home treatment is with cool to tepid baths and application of mid-potency corticosteroids under wet dressings or with the use of an occlusive plastic suit + Outcome Download Section PDF Listen +++ +++ Follow-Up ++ It may be impossible to identify the cause of exfoliative dermatitis early in the course of the disease, so careful follow-up is necessary +++ Complications ++ Debility (protein loss) and dehydration may develop in patients with generalized inflammatory exfoliative erythroderma Sepsis Systemic corticosteroids must be used with caution because some patients with erythroderma have psoriasis and could develop pustular flare +++ Prognosis ++ Most patients recover completely or improve greatly over time but may require long-term therapy Deaths are rare in the absence of cutaneous T cell lymphoma A minority of patients will suffer from undiminished erythroderma for indefinite periods +++ When to Refer ++ Early referral to dermatology is frequently helpful Diagnosis of cutaneous T cell lymphoma and/or Sézary syndrome should prompt referral to oncology +++ When to Admit ++ If the exfoliative erythroderma becomes chronic and is not manageable in an outpatient setting Keep the room at a constant warm temperature and provide the same topical treatment as for an outpatient + Reference Download Section PDF Listen +++ + +Inamadar AC et al. The rash that becomes an erythroderma. Clin Dermatol. 2019 Mar–Apr;37(2):88–98. [PubMed: 30981298]