Photo Quiz

Rapidly Progressive Erythroderma

 

Am Fam Physician. 2022 Jan ;105(1):75-76.

A 59-year-old man presented with a progressive full-body rash. The pruritic rash began on his extremities approximately six months earlier and was initially diagnosed as drug-related exanthem secondary to a calcium channel blocker. The patient was prescribed topical and oral steroids. Soon after finishing the steroids, his rash became progressively more widespread, involving the face, trunk, and all extremities. He also reported generalized weakness, small joint arthritis, and neuropathy. The patient did not have known contact allergens or exposures. His medical history included hypertension and hypothyroidism.

Physical examination revealed confluent erythroderma of the scalp, face, trunk, back, extremities, and groin (Figure 1). He had pitting edema and fissuring over both lower extremities with serous drainage. No nail involvement was observed. Two 4-mm punch biopsies were performed.

FIGURE 1


FIGURE 1

Question

Based on the patient's history and physical examination findings, which one of the following is the most likely diagnosis?

  • A. Atopic dermatitis.

  • B. Drug-induced erythroderma.

  • C. Erythrodermic pityriasis rubra pilaris.

  • D. Psoriasis.

  • E. Staphylococcal scalded skin syndrome.

Discussion

The answer is D: psoriasis. Psoriasis is the most common cause of erythroderma in adults.1 Erythroderma, also known as exfoliative dermatitis, is defined as erythema and scaling that comprise more than 80% of the body surface area.2 Erythroderma has numerous potential causes, making treatment difficult. About 50% of cases arise from a preexisting skin condition. Erythroderma can also be due to drug reactions or cutaneous T cell lymphoma.2,3 Because of the rapid cell turnover in erythroderma, many of the cell contents (e.g., nucleic acids, amino acids) are lost as the skin sloughs. This can lead to complications such as hypoalbuminemia, peripheral edema, high-output heart failure, anemia, lymphadenopathy, and hypo- or hyperthermia.2

Features of psoriatic erythroderma include preexisting psoriatic plaques, sparing of the central face, and nail changes (e.g., onycholysis, oil drop sign, pitting, subungual hyperkeratosis). The typical features of psoriasis can fade as the erythrodermic reaction becomes more widespread, with disseminated, sterile subcorneal pustules taking the place of plaques. This is commonly precipitated by the withdrawal of medications such as corticosteroids, methotrexate, or cyclosporine (Sandimmune).1,2

Atopic dermatitis erythroderma presents as a widespread intensely pruritic, erythematous rash. Lichenification with white scaling can occur, along with the preexisting eczematous lesions. Increased serum immunoglobulin E and eosinophils are nonspecific findings that may be present.2,3

Drug-induced erythroderma presents as fever, possible peripheral eosinophilia, lymphadenopathy, and hepatitis. Drug reactions caused by systemic medications usually begin as a morbilliform or scarlatiniform

Address correspondence to Summer Moon, DO, FAAD, at dr.summer.moon@gmail.com. Reprints are not available from the authors.

Author disclosure: No relevant financial relationships.

References

show all references

1. Cuellar-Barboza A, Ocampo-Candiani J, Herz-Ruelas ME. A practical approach to the diagnosis and treatment of adult erythroderma. Actas Dermosifiliogr (Engl Ed). 2018;109(9):777–790....

2. Bolognia JL, Schaffer JV, Cerroni L, eds. Dermatology. 4th ed. Elsevier; 2018.

3. Rothe MJ, Bialy TL, Grant-Kels JM. Erythroderma. Dermatol Clin. 2000;18(3):405–415.

4. Sehgal VN. Erythroderma/exfoliative dermatitis. In: Sehgal VN, ed. Textbook of Clinical Dermatology. Jaypee Bros.; 2004.

5. Gomez-Moyano E, Crespo-Erchiga A. Erythroderma secondary to pityriasis rubra pilaris. Indian J Med Res. 2019;150(2):206–207.

This series is coordinated by John E. Delzell Jr., MD, MSPH, associate medical editor.

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