04/08/23 1

2009

Departemen Ilmu Kesehatan Kulit dan Kelamin Fakultas Kedokteran

UNSRI/RSMH Palembang2011

M . IZAZI HP

Exfoliative dermatitis

dr. M. Izazi HP SpKK

characterized diffuse erythema & scaling involving >90% total body skin surface

Cause ED unknown, approximately 20% cases idiopathic ED

Exfoliative dermatitis (ED) or Erythroderma

04/08/23 2dr. M. Izazi HP SpKK

Exfoliative dermatitis (ED)

Common underlying etiologies psoriasis, atopic dermatitis, spongiotic dermatoses,drug hypersensitivity reaction, cutaneous T cell lymphoma(CTCL)

Systemic complications fluid & electrolyte imbalance, thermoregulatory disturbance, fever, tachycardi, High-output failure, hypoalbuminemia, peripheral edema

04/08/23 3dr. M. Izazi HP SpKK

Epidemiology

Incidence 0,9-71,0/100000 outpatient Male > female ratio 2,1 : 4,1 Average onset 41 – 61, rare children Many diseases associated ED

exacerbation previously localized disease >1/2

psoriasis identified almost ¼ cases

04/08/23 4dr. M. Izazi HP SpKK

Etiology

Drug Calcium channel blocker Anti-epileptic antibiotics (penicillin family, sulfonamides

vancomycin Allopurinol,gold,lithium Quinidine Cimetidine Dapsone

04/08/23 5dr. M. Izazi HP SpKK

ED atopic dermatitis

ED atopic dermatitis, psoriasis and CTCL Circulating intercellular adhesion molecule 1 (ICAM 1) Vascular cell adhesion molecule1 (VCAM1) E-selectin

04/08/23 6dr. M. Izazi HP SpKK

Possible trigger ED psoriasis

Discontinuation poten topical or oral CS, metotraxate, or biologic treatment (efalizumab)

Medicationlithium,terbinafine,antimalaria Topical irritanTar Infection HIV infections Pregnancy Emotional stress Systemic illness04/08/23 7dr. M. Izazi HP SpKK

Chronic Idiopathic ED

risk progression mycosis fungoides or sezary syndrome

Theorieschronic T-cell stimulation in chronic ED (atopic ED)promote developed CTCL

In elderly patients with chronic or relapsing ED monoclonal CD4+CD7- CD26- lymphocytes monoclonal T-cell dyscrasia of undertermined significance

04/08/23 8dr. M. Izazi HP SpKK

Pathogenesis

Not well understood Theorized staphylococcus aereus

colonization (83% in the nares& 17% skin &nares) or another antigen (shock syndrome toxin-1)

Cytokine profileTh1 cytokine profilebenign ED

Sezary syndrome Th2cytokine IgE

Different mechanism

04/08/23 9dr. M. Izazi HP SpKK

ED in psoriasis

Universal erythem, thickening skin, heavy scaling

Patient had fatigue,malaise, shivering

04/08/23 10dr. M. Izazi HP SpKK

BLEPHARITIS ED atopic dermatitis

Chronicity,edema,lichenification skin induration

Ectropion & epiphora secondary to chronic periorbital involvement

04/08/23 11dr. M. Izazi HP SpKK

ED in pityriasis rubra pilaris

04/08/23 12dr. M. Izazi HP SpKK

SEZARY SYNDROME

04/08/23 13dr. M. Izazi HP SpKK

Related physical finding

Thermoregulator disturbance hyperthermia/ hypothermiamost patients complain of feeling chilly

Tachycardiaincreased blood flow to the skin High-output cardiac failure Peripheral pedal or pretibial edema Generalized lymphadenopathy Hepatomegaly Splenomegaly

04/08/23 14dr. M. Izazi HP SpKK

Non specificAnemia, leucocytosis, lymphocitosis eosinophilia, IgE, ERSabnormal Electrolyte & creatinine

Sezary syndrome circulating cell sezary >20%Quantitative real-time PCR assay molecular diagnosis Sezary syndromePredominance CD4+

Laboratoric finding

04/08/23 15dr. M. Izazi HP SpKK

Complication

Systemic fluid & electrolyte imbalance Thermoregulatory disturbance Fever Hypoalbunemia Peripheral edema susceptibility bacterial colonization Sepsis CTCL & HIV (+) risk staphylococcus sepsis

04/08/23 16dr. M. Izazi HP SpKK

Treatment

fluid & electrolyte Replacement ED caused drug discontinous Enviroment warm & humid Preventing hypothermia Gentle local skin care Bland emollient

04/08/23 17dr. M. Izazi HP SpKK

Treatment

04/08/23 18dr. M. Izazi HP SpKK

Topical treatment

Started CS low potency CS high potency, immunomodulator

(tacrolimus) avoided Topical irritants (anthralin&tar) avoided

Systemic absorption

04/08/23 19dr. M. Izazi HP SpKK

Treatment systemic

Psoriasis EDSystemic CS avoided Psoriasis ED reponsive MTX,

cyclosporine,acitretin, mycophenolate mofetil, th/ biologic

04/08/23 20dr. M. Izazi HP SpKK

Treatment symptomatic

Sedating antihistaminpruritusDiuretica & leg elevation leg edema refractorySystemic antibiotic localized & systemic secondary infection Without evidence secondary infection as

bacterial colonization

04/08/23 21dr. M. Izazi HP SpKK

CBC=complete blood

cell

CXR=chest X-ray

PCP=primary care physician

Approach ED

04/08/23 22dr. M. Izazi HP SpKK

04/08/23 23dr. M. Izazi HP SpKK