Erythroderma is a dermatological emergency where widespread inflammation and erythema of the skin occurs, secondary to exfoliation of at least 90% of the skin surface – because of this, it’s sometimes also known as exfoliative dermatitis.
Pathophysiology
One of the problems in erythroderma is breakdown in the barrier function of the skin, alongside the fact that you’re losing a lot of skin in the way of exfoliation of the scales.
This results in the following:
- Hypothermia: Due to heat loss from the disrupted barrier of the skin
- Dehydration: Due to fluid losses from the skin
- Hypoalbuminaemia: From the loss of scaly skin via exfoliation
- Oedema: Resulting from the hypoalbuminaemia
Causes
- Pre-existing skin conditions e.g. psoriasis/atopic dermatitis, seborrheoic dermatitis
- Drug reactions – for example, rapid vancomycin infusion, anti-epileptics, lithium etc.
- Malignancy – cutaneous T-cell lymphoma
- Idiopathic
Clinical Features
- Erythematous skin with yellow/white scales (the latter being the exfoliating part – the scaling usually begins 2-6 days after the erythema starts)
- Skin warm to touch
- Oedema
- Pruritis
- Hypothermia
- Lymphadenopathy
- Evidence of underlying dermatological conditions: For example, presence of psoriatic plaques/psoriasis nail signs to help point towards the underlying cause of the erythroderma
Management
Management is largely conservative but this is something that requires hospital admission.
- Discontinue causative drugs: If there are any drugs which are not essential for the patient to be on, they can be discontinued
- Fluid balance maintenance: Monitoring input/output
- Thermoregulation: Keeping patients warm
- Monitor for infection: You can get secondary infections of the skin, and if these do occur then initiating antibiotics is sensible
- Pruritis: Oral antihistamines may be helpful for symptomatic relief
- Supportive therapies:
- Emollients
- Topical steroids
- Lukewarm baths
- Wet dressings
Complications
- Secondary infection due to disrupted barrier function of the skin
- Temperature dysregulation
- Electrolyte imbalance
- Fluid losses
- High output cardiac failure: In erythroderma, there’s an increase in perfusion to the skin – that peripheral vasodilation can result in a high-output cardiac failure (high-output cardiac failure is where the heart is working fine i.e. cardiac output is high, but it is insufficient to meet the body’s demands – it often happens in low systemic vascular resistance states)
References
https://emedicine.medscape.com/article/1106906-overview#a5
https://www.ncbi.nlm.nih.gov/books/NBK513337/
https://www.ncbi.nlm.nih.gov/books/NBK554568/#:~:text=Erythroderma%20is%20a%20clinical%20finding,and%20manage%20this%20condition%20appropriately
https://dermnetnz.org/topics/erythroderma
https://www.emjreviews.com/allergy-immunology/article/erythroderma-a-manifestation-of-cutaneous-and-systemic-diseases/
