Erythroderma implies generalized redness and infilteration of theintegument as is evident in pityriasis rubra pilaris, generalized dermatitis due to drugs and reticuloses. When accompanied by marked scaling and exfoliation of the skin, the term exfoliative dermatitis is employed. In reality both terms mean more or less the same thing.
Erythroderma, meaning 'redskin', refers to the clinical state of inflammation or redness of all (or nearly all) of the skin. It is sometimes called exfoliative dermatitis, but dermatitis is not always present. It is commoner in males and later in life. Patients often complain of their skin feeling 'tight' as well as itchy. Long-standing erythroderma is often associated with hair loss, ectropion of the eyelids and even nail shedding. Systemic symptoms are common, such as malaise, pyrexia, widespread lymphadenopathy and possible serious circulatory disturbance. Erythroderma can occasionally lead to death, so it should be regarded as a medical 'emergency'.
There are a number of underlying causes (Table 22.7) and a careful history should be sought, paying particular attention to previous skin disease and any drug history. Examination should specifically look for pustules and nail changes suggestive of psoriasis. A skin biopsy may further help to elucidate the cause, especially of cutaneous lymphoma. Techniques such as T-cell receptor gene rearrangement studies (looking for evidence of clonal T-cell expansion in the skin and blood) are also useful in the diagnosis of lymphoma.
A number of cases defy an exact diagnosis. Lymph node biopsy should be considered in lymphoma. In non-malignant disease lymph nodes normally show non-specific, reactive (dermatopathic) changes.
The skin is one of the largest organs of the body; perhaps it is no surprise that inflammation of the whole organ can cause metabolic and haemodynamic problems. Examples are:
Capillary leak syndrome is the most severe complication and has been responsible for a fatal outcome in some cases of psoriasis, although this is extremely rare. It is thought that the inflamed skin releases large quantities of cytokines that cause a generalized vascular leakage. This can cause cutaneous oedema but more worryingly can cause leaky vessels in the lungs, resulting in acute lung injury.
Treatment of erythroderma is best initiated in hospital. Patients must be kept very warm (with space blankets and heaters) and put on fluid-balance charts. Their vital signs should be monitored regularly. Changes in electrolytes, albumin and circulatory status should be corrected. Swabs should be taken to detect any secondary skin infection.
The skin condition is treated with bed rest and either a bland emollient or a mild topical steroid. All unessential drugs should be stopped. Where known, the underlying cause should be treated appropriately. The blanket use of systemic steroid therapy for erythroderma remains controversial in view of possible side-effects.
Advanced capillary leak syndrome will often require specialized haemodynamic management in an intensive care unit.
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