Dermatitis, Exfoliative

Author: Therese I McBride, DO, Assistant Professor, Department of Emergency Medicine, University of Arkansas for Medical Sciences
Coauthor(s): Barry E Brenner, MD, PhD, FACEP, Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, University Hospitals, Case Medical Center
Contributor Information and Disclosures

Updated: Feb 25, 2010

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• Overview
• Differential Diagnoses & Workup
• Treatment & Medication
• Follow-up

• References
• Keywords

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Introduction

Background

Exfoliative dermatitis, or erythroderma, is an erythematous, scaly dermatitis involving most, if not all, of the skin. This generalized scaling eruption of the skin is drug induced, idiopathic, or secondary to underlying cutaneous or systemic disease.

Appreciation for this condition requires an understanding of the skin's normal epithelial layer. Normal epidermis has a continual turnover of epithelial cells. Cell division occurs near the basal layer. As cells move toward the periphery, they become well keratinized. This process requires approximately 10-12 days. Cells subsequently remain in the stratum corneum for another 12-14 days prior to being sloughed off.

In exfoliative dermatitis, the mitotic rate in the basal layer increases and overall transit time decreases; therefore, more cells are lost from the surface. The mechanism responsible for this is not known, although an immunologic basis has been suggested.

Pathophysiology

Exfoliative dermatitis may occur in response to drug therapy, systemic disease, or an idiopathic entity. As many as 40% of cases involve preexisting cutaneous disease. Approximately 10% of cases are the result of drug reactions. As many as 40% are caused by underlying systemic disease. The remaining cases are idiopathic.

Histopathologic patterns observed for drug-induced and idiopathic causes of exfoliative dermatitis are nonspecific. Biopsy findings in individuals with preexisting cutaneous or systemic disease during an exfoliative stage may reveal, inconsistently, the underlying skin lesion or pathology. Through multiple-biopsy histologic analysis, the diagnosis may be confirmed in as many as 45% of patients.

Frequency

United States

An estimated 1% of hospitalizations are for skin disease.

International

The ratio of hospitalized patients experiencing adverse drug reactions is 3 in 1000. According to one large Finnish study, approximately 1% of these instances involve exfoliative dermatitis.

Mortality/Morbidity

The mortality rate approaches 30%. In a report of 108 patients with exfoliative dermatitis who were autopsied, 87 died from the underlying disease. No cause other than exfoliation was found for the remaining 17 patients.

Race

Exfoliative dermatitis occurs in all races. In the young black male population, research suggests exfoliative dermatitis may be a marker for HIV infection.

Sex

The male-to-female ratio is 2:1.

Age

Individuals older than 40 years are affected most frequently.

Clinical

History

• Prior dermatologic illnesses¹
• Treatment with new medications
• Underlying systemic diseases
  • Swelling or adenopathy
  • Recurrent infections
  • Cough or change in bowel or urinary habits
• Constitutional symptoms of low-grade fever, chills, and malaise (more commonly, patients complain of skin erythema, tightness, and scaling)

Physical

• Gynecomastia is a common finding in almost all patients with exfoliative dermatitis of several weeks' duration; it is believed to be secondary to hyperestrogenism, but the precise mechanism is unknown.
• Additional findings include alopecia, dystrophic nails, and hypopigmentation and/or hyperpigmentation.
• More than 40% of patients were febrile, with temperatures higher than 38°C; a relative tachycardia also was noted.
• Firm, rubbery lymphadenopathy, referred to as dermatopathic lymphadenitis, is a common finding.
• Hepatomegaly was noted in more than 50% of patients in one series, and splenomegaly was noted in approximately 30% of patients, all of whom had lymphoma.
• Steatorrhea may develop and tends to resolve when exfoliative dermatitis clears.
• Patients with exfoliative dermatitis have increased cutaneous blood flow, transcutaneous fluid losses, and radiation and convective heat losses.
  • A number of cases of hypothermia have been reported.
  • Fluid shifts increase cardiac output, causing dyspnea, dependent edema, and cardiac failure (possibly) in some patients.
• Prostate or thyroid glands may be enlarged or nodular.

Causes

• Systemic diseases (10-40%)
  • Lymphoma - Primarily cutaneous T-cell lymphoma (CTCL)
  • Leukemia
  • Multiple myeloma
  • Carcinoma of the lung, prostate, colon, and thyroid
  • Graft versus host disease
  • Immunodeficiency, including HIV
  • Hodgkin disease
• Cutaneous diseases (10-40%)
  • Psoriasis
  • Seborrheic dermatitis
  • Atopic dermatitis
  • Stasis dermatitis
  • Contact dermatitis
  • Pityriasis rubra pilaris
  • Pemphigus foliaceus
  • Mycosis fungoides
  • Dermatophytosis
  • Lichen planus
• Drugs (3-10%)
  • Dimercaprol (British antilewisite [BAL])
  • Codeine
  • Captopril
  • Diphenylhydantoin
  • Gold
  • Iodine
  • Antimicrobials - Sulfas, penicillin (PCN), cephalosporins, minocycline, isoniazid
  • Granulocyte colony-stimulating factor (GCSF)
  • Phenytoin
  • Allopurinol
  • Mercury
  • Arsenic
  • Quinidine
  • Barbiturates
  • Trimethadione
  • Aspirin
  • Carbamazepine
• Idiopathic (15-45%)