ERYTHRODERMA ASAPA 2018 Fall Conference Tucson, AZ 10/12/2018 Andrew Newman, DO Pgy-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)
Erythroderma is NOT a specific diagnosis COMMON CAUSES OF ERYTHRODERMA 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
NO MATTER WHAT THE CAUSE IS INITIAL MANAGEMENT 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
Vitals: T 100.4, BP 98/70, HR 120, RR 16, O2 97% Not acutely distressed Diffuse redness and silver scale CASE ONE CONT
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
Vitals: T 100.1, BP 98/70, HR 108, RR 18, O2 96% Not acutely distressed Diffuse redness, lion-like face, thickened skin. CASE 2 CONT
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, hx of 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 lionlike 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.