Erythroderma

Table of Contents

Table of Contents

Published July 2021

Gil Weintraub, MD1
Mollie Oudenhoven, MD2
Molly Weinberg, MD3
Mariam Alam, MD4

1 Assistant Professor, Department of Dermatology, University of Colorado 2 Clinical instructor, Department of Pediatrics and Chief Resident in Dermatology, University of Colorado 3 Clinical Instructor, Department of Medicine, University of Colorado 4 Clinical Instructor, Department of Medicine and Resident in Dermatology, University of Washington

Objectives

  1. Identify erythroderma by diffuse erythema without mucosal involvement or bullous formation.
  2. Describe the differential for erythroderma and the next steps in the diagnostic workup.
  3. Describe the management of diffuse barrier including correction of fluid and electrolyte imbalances, nutritional support, prevention of hypothermia, and treatment of secondary infections.

Teaching Instructions

Plan to spend 5-10 minutes practicing the flow of the presentation and reviewing the images of squamous cell carcinoma provided.

Present the images by expanding the window below or downloading the PowerPoint file (preferred). Ask the learners to provide a description of the lesions they are viewing. Advance using the arrows or scroll wheel on the mouse to reveal subsequent questions with answers and graphics.

Dermatology description: Erythematous patches with scattered areas of sparing appearing to involve >90% of body surface. Minimal overlying scale. No blistering, ulceration or erosions. No mucosal involvement.

Diagnosis: Erythroderma (a clinical sign, not a diagnosis)

Teaching:

Erythroderma implies diffuse erythema and may include scale involving > 90% of body surface area. Erythroderma is technically a clinical sign, not a diagnosis, and may represent the clinical presentation of a WIDE range of cutaneous and systemic diseases including but not limited to: psoriasis (think about recent oral steroid taper), atopic dermatitis, allergic contact dermatitis, drug hypersensitivity reaction, cutaneous T cell lymphoma/Sezary syndrome, seborrheic dermatitis (Think about immunosuppressed patients, like in HIV),  scabies, cutaneous T cell lymphoma, GVHD, staph scalded skin or other. Nearly ¼ of cases are ultimately idiopathic. The mortality rate of erythroderma is over 5%

Question 3: What is your next step in evaluation?

The initial evaluation should include:

1. A thorough history
Recommend screening for any new medications, family or personal history of psoriasis, the recent withdrawal of corticosteroids, occupation, and hobbies.

Pro tip: Drugs most commonly associated with Erythroderma include

Allopurinol, Beta-lactam antibiotics, Carbamazepine, Phenobarbital, Phenytoins, Sulfasalazine, SUlfonamides, Zalcitabine

2. Physical Exam looking for evidence of blistering, mucosal involvement, and lymphadenopathy, or superficial infection (herpetic or staphylococcal)

3. Initial blood work, in part guided by your history. Some common labs include: CBC with differential, Basic Metabolic Panel, Liver function test, and HIV test.

4. Punch or shave biopsy over involved skin.

Presentation Board

Take Home Points

  1. Erythroderma is >90% body surface area without blistering or full-thickness sloughing of skin.
  2. While there are many potential causes, it is important to screen for potential trigger medications (especially recent tapers of glucocorticoids), get baseline screening labs including HIV, and perform or request a biopsy.
  3. Erythroderma patients have homeostasis dysfunction, so you should monitor closely for hypothermia, hypovolemia, nutrition deficiency, and secondary skin infections. 

References

Whittaker, S. Erythroderma. In: Bolognia L eds. Dermatology.  4th edition. Elsevier; 2018: 175-183. 

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