ERYTHRODERMA

7/13/2019 ERYTHRODERMA

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ERYTHRODERMA


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Complaints-usually redness,itching, sense of

tightness and fever

History present illness-

duration,progression,history of remissions and

exacerbations

History related to etiology-itching,fever,type of

scaling,vesicles and bulla

h/o joint pain


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H/o Medications

H/o Atopy

H/o loss of weight and appetite

H/o photosensitivity,muscle weakness

H/o bleeding tendency.

h/o previous infection ( dermatophyte,scabies)

h/o organ transplantation


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H/o related to complications of erythroderma

H/o difficulty in

breathing,palpitation,diarrhoea

H/o fever,chills,skin infections


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Personal history:

Occupation-contact with cement,plants

Marital history,sexual history Smoking and alcohol abuse


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FAMILY HISTORY

Skin disease-ichthyosis,atopy,scabies


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General examination:

temperature,pulse rate,respiratory

rate,CVS,RS,Abdomen,PV,PR,lymph nodes


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Dermatological examination

look for any clues to etiology-like

plaques,papules,vesicles,burrow,

Hair,Nails, oral mucosa

genitals


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Bedside investigations

Scraping for fungus,scabies

Nikolsky sign,Asboe Hansen sign Peripheral smear


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ERYTHRODERMA/EXFOLIATIVE

DERMATITIS

HISTORY:

Hebra -1868

Wilson Brocq-chronic relapsingHebra-progressing

Savil-self limited

Males affected more commonly-2-4 times


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Causes of erythroderma in adults

Hereditary disorders

Ichthyosiform erythroderma,pityriasis rubrapilaris,Psoriasis,Reiters,seborrhoeic dermatitis

Eczemas of various types-atopic,venouseczema,chronic actinic dermatitis

Drugs-arsenic,gold,mercury,pencillin,barbiturates,carbamazepine,cimetidine,lithium,allopurinol,antimalarials,cephalospirins,sulphonamides,dapsone,phenobarbitone,phenybutazone,asprin,catopril,INH,

SM,Vitamin A


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Bullous disorders-pemphigus foliaceous

Lymphomas and leukaemias

OTHER SKIN DISEASES Lichen planus

Dermatophytosis-trichophyton violaceum

Crusted scabies dermatomyositis


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UNKNOWN

RARE CAUSES

Sarcoidosis,Hailey-hailey,pemphigoid,toxicshock syndrome,LE,angioimmunoblasticlymadenopathy,GVHD

carcinoma lungs,carcinoma rectum,multiplemyeloma,mycosis fungoides,reticulum cellsarcoma


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Erythroderma in neonates and infants

1)ICHTHYOSIS:NBIE,BIE,Nethertonsyndrome,Conradi Hunermannsyndrome,lamellar

ichthyosis,Trichothiodystrophy 2)INFECTIONS-SSSS,scarlet fever,neonatal

candidiasis,toxic shock syndrome

3)INFESTATIONS-Norwegian scabies 4)IMMUNODEFICIENCY-Omenns

syndrome,GVHD


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5)DRUG INDUCED:ceftroxone,vancomycin,antiepileptics,sulphonamides,antitubercular drugs,homeopathic and indigenousmedicines

6)METABOLIC/NUTRITIONALDisorders of biotin metabolism,EFAdeficiency,kwashiokar,acrodermatitisenteropathica,cystic fibrosis,Leinersdisease,multiplecarboxylase deficiency

7)OTHER DISORDERS:infantile seborrhoeicdermatitis,atopic dermatitis,psoriasis,PRP,diffusecutaneous mastocytosis


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Causes of erythroderma in preschool

and school going children

1)Ichthyosis

2)Atopic dermatitis

3)Infestations-norwegian scabies 4)papulosquamous diorder-psoriasis,PRP

5)Drugs-

antiepileptics,sulphonamides,antituberculardrugs,homeopathic and indigenous medicines


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6)Metabolic/nutritional-

kwashiorkar,acrodermatitis enterpathica,cystic

fibrosis,cutaneous T cell lymphoma

7)Miscellaneous and rare disorders

Kwashiorkar

disease,dermatomyositis,sarcoidosis,

Pemphigus

8)idiopathic


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Causes of erythroderma in AIDS

1)seborrhoeic dermatitis

2)lymphoma

3)drug induced erythroderma


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Dermatological manifestations

Starts as erythematous patches-

Covers entire skin in days to weeks

Bacterial colonisation-crusting Chronic-induration,thickening and

lichenification

Clues of previous skin disease may be found


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Erythroderma of eczema and lymphoma-sudden onset,intensity may fluctuate overperiods.

Irritation may be severe and sense oftightness

Venous eczema-6 or 7 decade

Atopic eczema-any agePruritus often intense.Increased Ig E andeosinophilia


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Psoriatic erythroderma-features of psoriasis

often lost.Miliary pustules may develop

Stress,intercurrent illness,drugs,phototherapy

Pemphigus foliaceous-thin walled vesicles

PRP-childhood or adult.Islands of normal skin

persist even in erythroderma.horny plugs-maybe seen.palms and soles-orange

discolouration


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Drug induced erythroderma

start in flexures or whole skin

Scarlatiniform or morbilliform rash

Nails- shore line nails Best prognosis-resolves in 2-6 weeks

DRESS SYNDROME-drug reaction with

eosinophilia and systemic symptoms.

Erythroderma in lymphoma and


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Erythroderma in lymphoma and

leukaemia

Pruritus is often severe,secondary

lichenification.

Erythrodermauniversal

Lymph nodes,hepatosplenomegaly


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Lichen planus-after erythema subsides-

violaceous papules.

Mucosa-bluish white streaks

Norwegian scabies-generalised with

involvement of face and palms

H/oitching in contacts

Dermatomyositis-gottronspapules,muscle

weakness,heliotrope rash


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RED MAN SYNDROME

Chronic erythroderma of unknown origin in

elderly men.

Long course

PPK,dermopathic lymphadenopathy,increased

serum Ig E.


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Papuloerythroderma of Ofugi

Elderly men

Flat topped papules-plaques

Deck chair sign


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Nail changes

Thickened,ridged,dull and brittle

Subungual hyperkeratosis,onycholysis,splinter

haemorrage

Beaus lines

Shoreline nails

Shiny nails-constant itching


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Palmoplantar keratoderma

Mucosa-usually not involved.

Generalised vitiligo,disseminated pyogenicgranuloma,anhidrosis,xanthoma,pigmentary

changes-after resolution


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Systemic associations

1)axillary and inquinal lymadenopathy-

dermatopathic lymphadenopathy-62%

2)Hepatosmegaly-37%

3)splenomegaly-23%

4)Poikilothermia

5)increased transepidermal water loss


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Vascular changes-tachycardia,high output

cardiac failure,right sided heart failure,IHD

Increased BMR,loss of weight

Renal insufficiency

Protein loss and negative nitrogen balance

Pulmonary capillary leak syndrome & ARDS


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Gynaecomastia

Anaemia

GIT-malabsorption


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LAB INVESTIGATIONS

Complete haemogram-Hb,eosinophils,ESR

Peripheral smear,Tzanck

Motion for occult blood

X-ray chest,ECG

USG abdomen

Serum electrolytes,creatinine

LDH

LFT-protein level

Blood glucose

Gamma globulin,Ig E


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SKIN BIOPSY

LYMPHNODE BIOPSY

IMMUNOFLOURESCENCE.

IMMUNOHISTOCHEMISTRY


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IN CHILDREN

Complete blood count,hair mount,grams stain

Immunoglobulin assay,sweat chloride levels

Zinc and alkaline phosphatase levels

Biotinidase and holocarboxylase and EFA

Gene analysis-SPINK-5


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HISTOPATHOLOGY IN ERYTHRODERMA

Diagnostic value is conflicting-50%

Multiple biopsy

Useful in T-cell related erythroderma

Nonspecific,subacute and chronic spongiotic

dermatitis.

Drug related erythroderma Psoriatic erythroderma-early lesions of

psoriasis


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Prognosis and complications

Serious condition.Elderly patients-prognosis

guarded.

Erythroderma due to psoriasis and eczema-

may continue for months and years.

Good prognosis-drug induced erythroderma

Hypothermia,cardiac

decompensation,peripheral circulatory

failure,respiratory infection.


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MANAGEMENT

Admission

Maintenance of environmental temperature

Fluid-intake output chart

Urea electrolyte balance-monitored

Protein diet and folate supplementation

Bland emollients,soaks,compresses

Topical steroid.

Antihistamines and antibiotics


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Treatment of underlying cause

Psoriasis-

cyclosporine,methotrexate,acitretin,MMF

PRP-Retinoids,steroids,

Drug reaction-steroids,immunoglobulins

T-cell lymphoma-steroids,electron beamtherapy,chrorambucil


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To summarise

Idiopathic-25%

Psoriasis-23%

Eczema-16%

Cutaneous T-cell lymphoma-16%

Drug reaction-15%


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THANK YOU

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ERYTHRODERMA