ERYTHRODERMAASAPA 2018 Fall ConferenceTucson, AZ 10/12/2018

Andrew Newman, DOPgy-3, Affiliated Dermatology/Honor Health

OBJECTIVES

• Define Erythroderma• Name common diseases and medications that cause

erythroderma• Explain morbitidy in erythrodermic patients• Discuss the initial management of the erythrodermic patient• Cases• Take-home points

DEFINE ERYTHRODERMA

• A generalized redness and/or scaling of at least 90% of Body Surface Area (BSA)

COMMON CAUSES OF ERYTHRODERMA

• Erythroderma is NOT a specific diagnosis• Drug (40%)

• Antibiotics, calcium channel blockers, allopurinol, lithium, anti-epileptics• Psoriasis (20%)• Idiopathic (10%)• Eczema/atopic dermatitis (10%)• Lymphoma/mycosis fungoides (10%)• Others: Dermatomyositis (DM), Seborheic Dermatitis, Contact dermatitis,

Pytiariasis Rubra Pilaris (PRP)***Percentages vary between sources

ERYTHRODERMA MORBIDITY

• Complications include sepsis and high-output heart failure

• Dehydration and electrolyte abnormalities• Cardiorespiratory decompensation• Hospitalization may be necessary• Dermatology consult is essential

INITIAL MANAGEMENT

• NO MATTER WHAT THE CAUSE IS…

• Remove potential offending/unnecessary medications

• Address fluids and electrolytes• Wet dressings and topical steroids (like TAC)

CASE ONE• CL is a 64 yo man presenting to the dermatology clinic with

a rapid progression of redness covering most of his body. He recently was discharged from the hospital after an acute exacerbation of COPD, where he was treated with Levaquin and IV corticosteroids.

• PMH: COPD, HTN, Dyslipidemia, psoriasis• Meds: Resp inhalers, ACE inhibitor, statin, topical Clobetasol• Allergies: none• FH: heart disease and psoriasis and hypothyroidism• SH: tobacco user. No recreational drugs/etoh• ROS: fatigue

CASE ONE CONT…

• Vitals: T 100.4, BP 98/70, HR 120, RR 16, O2 97%

• Not acutely distressed

• Diffuse redness and silver scale

WHAT IS THE MOST LIKELY DIAGNOSIS?

• A). Cutaneous T-cell Lymphoma• B). Idiopathic• C). Psoriatic erythroderma• D). Atopic dermatitis

WHAT IS THE MOST LIKELY DIAGNOSIS?

• A). Cutaneous T-cell Lymphoma• B). Idiopathic• C). Psoriatic erythroderma• D). Atopic dermatitis

ERYTHRODERMIC PSORIASIS

• PMH and/or FH of psoriasis• Acute or subacute onset

following:• Emotional stress• Medication • Infection• DISCONTINUATION OF

PSORIASIS TREATMENT (PREDNISONE)

• Treatment:• Potent topical steroids

• MTX or biologic (ie. anti-TNF)

ERYTHRODERMIC PSORIASIS WORK UP• Total IgE, CBC/CMP, CRP, ANA w/ reflex ab panel, rapid

strep (help with diagnosis)

• Cocci titers, Quantiferon, Hep panel, HIV (all for anticipating initiation of biologic)

• Two skin biopsies

• Start topical betamethasone augmented cream and discuss adalimumab for near future.

CASE TWO• NS is a 52 yo man admitted for a full-body rash. His rash had

slowly progressed over 2 years prior to dramatically worsening over the past week. The man had admitted to having multiple skin biopsies in the past which were inconclusive. He was started on IV fluids and broad spectrum antibiotics for presumed sepsis. Dermatology was consulted.

• PMH: Cerebral Vascular Accident and Traumatic Brain Injury • Meds: Baby aspirin, topical triamcinolone cream• Allergies: none• FH: none• SH: on disability from CVA• ROS: Diffuse itchiness

CASE 2 CONT…

• Vitals: T 100.1, BP 98/70, HR 108, RR 18, O2 96%

• Not acutely distressed

• Diffuse redness, lion-like face, thickened skin.

WHAT IS THE MOST LIKELY DIAGNOSIS?

• A). Cutaneous T-cell Lymphoma• B). Drug-induced• C). Psoriatic erythroderma• D). Atopic dermatitis

WHAT IS THE MOST LIKELY DIAGNOSIS?

• A). Cutaneous T-cell Lymphoma (ie. mycosis fungoides/sezzary syndrome) (Thick lion-like facial skin, hxof multiple non-specific skin bxs)

• B). Drug-induced (no new/suspect drugs, not acute, initial hive-like rash or morbilliform-like rash)

• C). Psoriatic erythroderma (no thicken silver scale, no nail findings, no FH/PMH of psoriasis)

• D). Atopic dermatitis (no hx of eczema/asthma/allergy rhinitis)

MYCOSIS FUNGOIDES (MF)• Most common form of Cutaneous T-Cell Lymphoma• Sezzary Syndrome (SS) is MF plus numerous abnormal

“sezzary cells” in serum• MF/SS can cause erythroderma with thickened skin and lion-

like facies• Often involves hands and feet• May spare the skin folds

• Skin biopsies COULD help in dx• Peripheral blood smear to dx SS.

MF/SS WORK-UP/TREATMENT

• IgE, CBC/CMP, CRP, ANA w/ reflex ab panel• SPEP, UPEP• Three 4mm punch biopsies of skin• Stat peripheral blood smear x2 (Pt was positive for many

Sezzary cells)• CALL HEME/ONC

• Topical triamcinolone cream, hydroxyzine ATC, 14 days of Keflex to prevent secondary infections, heme/onc to do chemotherapy.

REFERENCES

1. Bruno TF, Grewal P. Erythroderma: a dermatologic emergency. CJEM. 2009; 11:244-6

2. Grant-Kels Jane M, Bernstein Megan L, Rothe Marti J, “Chapter 23 . Exfoliative Dermatitis” (Chapter). Wolff K, Goldsmith LA, Katz SI, Gillchrest B, Paller AS, Leffell DJ: Fitzpatrick’s Dermatology in General Medicine, 7e.