Sections

Erythroderma (Generalized Exfoliative Dermatitis)

Sections Erythroderma (Generalized Exfoliative Dermatitis)
Overview
Presentation
DDx
Workup
Treatment
Medication
Media Gallery
Tables
References

Overview

Practice Essentials

Erythroderma is a general term used to describe severe, intense skin inflammation; exfoliative dermatitis (ED) refers to a scaling erythematous dermatitis involving 90% or more of the cutaneous surface. Exfoliative dermatitis is characterized by erythema and scaling involving the skin's surface and often obscures the primary lesions that are important clues to understanding the evolution of the disease.

The most common causes of exfoliative dermatitis are best remembered by the mnemonic device ID-SCALP. The causes and their frequencies are as follows^[1]:

Idiopathic - 30%
Drug allergy - 20%
Seborrheic dermatitis - 2%
Contact dermatitis - 3%
Atopic dermatitis - 10%
Lymphoma and leukemia - 14%
Psoriasis - 20%

Clinicians are challenged to find the cause of exfoliative dermatitis by eliciting the history of illness prior to erythema and scaling, by probing with biopsies, and by performing blood studies. See the images below.

Exfoliative dermatitis diffuse skin involvement.

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Exfoliative dermatitis close-up view showing erythema and scaling.

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Idiopathic exfoliative dermatitis is characterized by marked palmoplantar keratoderma, dermatopathic lymphadenopathy, and a raised level of serum immunoglobulin E (IgE) and is more likely to persist than other types.

A non-IgE-mediated anaphylactoid adverse event characterized by pruritus, erythroderma, wheezing, flushing, and hypotension following rapid infusion of vancomycin was originally named Red man syndrome (RMS). It has since been reported with oral or topical vancomycin.^[2] The use of the term 'red man syndrome' is now discouraged as it leads to underdiagnosis among non-White patients.^[3]

In contrast, L'homme rouge historically refers to either idiopathic exfoliative dermatitis or exfoliative dermatitis often secondary to cutaneous T-cell lymphoma (CTCL). Regarding CTCL, it is important to differentiate between indolent and aggressive subtypes, particularly erythrodermic mycosis fungoides and Sézary syndrome, as treatment options differ.^[4]

Next: Pathophysiology

Pathophysiology

An increased skin blood perfusion occurs in exfoliative dermatitis (ED) that results in temperature dysregulation (resulting in heat loss and hypothermia) and possible high-output cardiac failure. The basal metabolic rate rises to compensate for the resultant heat loss. Fluid loss by transpiration is increased in proportion to the basal metabolic rate. The situation is similar to that observed in patients following burns (negative nitrogen balance characterized by edema, hypoalbuminemia, loss of muscle mass).

A marked loss of exfoliated scales occurs that may reach 20-30 g/d. This contributes to the hypoalbuminemia commonly observed in exfoliative dermatitis. Hypoalbuminemia results, in part, from decreased synthesis or increased metabolism of albumin. Edema is a frequent finding, probably resulting from fluid shift into the extracellular spaces. Immune responses may be altered, as evidenced by increased gamma-globulins, increased serum IgE in some cases, eosinophil infiltration, and CD4⁺ T-cell lymphocytopenia in the absence of HIV infection. Oxidative stress is also associated with drug-induced erythroderma.^[5]

Chronic erythroderma in elderly men may represent a unique condition distinct from adult atopic dermatitis.^[6]

Next: Pathophysiology

Etiology

Determining specific etiologies in exfoliative dermatitis (ED) often is not possible; however, it is necessary to attempt since etiology may impact disease course and management options. The list of conditions that can cause exfoliative dermatitis is extensive and continues to expand. Cutaneous diseases that cause exfoliative dermatitis and the systemic diseases associated with them include the following^{[7, 8, 9]}:

Atopic dermatitis - Acute and chronic leukemia
Contact dermatitis - Reticulum cell sarcoma
Dermatophytosis - Carcinoma of rectum
Hailey-Hailey disease - Carcinoma of fallopian tubes
Leiner disease - Graft versus host disease
Lichen planus - HIV infection
Lupus erythematosus - Lymphoma (including Hodgkin disease)
Mycosis fungoides - Multiple myeloma
Pemphigoid - Carcinoma of lung
Pemphigus foliaceus - Mycosis fungoides
Pityriasis rubra pilaris - Reactive arthritis
Psoriasis
Sarcoid
Seborrheic dermatitis
Stasis dermatitis

The most common causes of exfoliative dermatitis are best remembered by the mnemonic device ID-SCALP. The causes and their frequencies are as follows^[1]:

Idiopathic - 30%
Drug allergy - 20%
Seborrheic dermatitis - 2%
Contact dermatitis - 3%
Atopic dermatitis - 10%
Lymphoma and leukemia - 14%
Psoriasis - 20%

More than 135 drugs have been implicated in the causation of exfoliative dermatitis (see Table 1 below). In many cases of protracted exfoliative dermatitis classified as being of undetermined cause, careful follow-up care and reevaluation implicated atopic dermatitis in older patients, intake of drugs overlooked by the patient, and prelymphomatous eruption as causative factors. It should be noted that psoriasiform erythroderma has been induced by the tumor necrosis factor (TNF)-α inhibitor golimumab.^[10]

Table 1. Drugs Implicated in the Causation of Exfoliative Dermatitis (Open Table in a new window)

99mTC-sestamibi^[11]	ACE inhibitors	Allopurinol	Aminoglutethimide	Amiodarone
Amitriptyline	Amoxicillin	Ampicillin	Angiogenetic inhibitors^[12]	Arsenic
Aspirin	Atropine	Auranofin	Aurothioglucose	Barbiturates
Benactyzine	Beta-blockers	Beta carotene	Bumetanide	Bupropion
Butabarbital	Butalbital	Captopril	Carbamazepine	Carbidopa
Cephalosporins^[13]	Chloroquine	Chlorpromazine	Chlorpropamide	Cimetidine
Ciprofloxacin	Cisplatin	Clofarabine^[14]	Clofazimine	Clofibrate
Co-trimoxazole	Cromolyn	Cytarabine	Dapsone	Demeclocycline
Desipramine	Diazepam	Diclofenac	Diflunisal	Diltiazem
Doxorubicin	Doxycycline	Efavirenz^[15]	Enalapril	Escitalopram^[16]
Esomeprazole^[17]	Ethambutol^[18]	Etodolac	Fenofibrate^[19]	Fenoprofen
Fluconazole	Fluindione^[20]	Fluoxetine^[21]	Fluphenazine	Flurbiprofen
Furosemide	Gemfibrozil	Gliclazide^{[22, 1]}	Glipizide^[23]	Gold
Griseofulvin	Hydroxychloroquine	Imatinib^{[24, 25]}	Imipramine	Indomethacin
Intravenous immunoglobulin^[26]	Intravesical mitomycin C^[27]	Iodixanol^[28]	Isoniazid	Isosorbide
Ketoconazole	Ketoprofen	Ketorolac	Leflunomide^[29]	Lithium
Meclofenamate	Mefenamic Acid	Meprobamate	Methylphenidate
Midodrine^[30]	Minocycline	Morphine sulfate^[31]	Nalidixic Acid	Naproxen
Nevirapine^[32]	Nitrazepam^[23]	Nifedipine	Nitrofurantoin	Nitroglycerin
Nizatidine	Norfloxacin	Omeprazole	Pantoprazole^[33]	Penicillamine
Penicillin	Pentobarbital	Perphenazine	Phenobarbital	Phenothiazines
Phenylbutazone	Phenytoin	Piroxicam	Primidone	Prochlorperazine
Propranolol	Pyrazinamide^[18]	Pyrazolones	Quinapril	Quinidine
Quinine	Retinoids	Rifampin	Sorafenib^[34]	Streptomycin
Strontium ranelate^[35]	Sulfadoxine	Sulfamethoxazole	Sulfasalazine	Sulfisoxazole
Sulfonamides	Sulfonylureas	Sulindac	Terbinafine^[36]	Tetracycline
Tobramycin	Tocilizumab^[37]	Trazodone	Trifluoperazine	Trimethoprim
Vancomycin	Verapamil	Warfarin^[38]

Sarcoidosis-associated erythroderma may demonstrate lichenoid papules as a clue to the diagnosis.^[39]

Next: Pathophysiology

Epidemiology

Age-, sex-, and race-related demographics

Exfoliative dermatitis onset usually occurs in persons older than 40 years, except when the condition results from atopic dermatitis, seborrheic dermatitis, staphylococcal scalded skin syndrome, or a hereditary ichthyosis. Age of onset primarily is related to etiology.^{[40, 41]}

Male-to-female ratio is 2-4:1.

No racial predilection is reported for exfoliative dermatitis.

Next: Pathophysiology

Prognosis

The prognosis of exfoliative dermatitis depends largely on underlying etiology. The disease course is rapid if it results from drug allergy, lymphoma, leukemia, contact allergens, or staphylococcal scalded skin syndrome. In acute erythroderma, skin failure can be life-threatening and can require treatment in the intensive care unit (ICU). Systemic complications are less frequent in chronic presentations.^[1]

A study^[42]of pediatric patients (aged < 19 y) found that fever is a poor prognostic marker and may indicate a susceptibility to rapid deterioration. In this group, those with the following characteristics have a higher tendency to develop hypotension:

Age ≤ 3 years
Ill appearance
Vomiting
Glucose ≤ 110 mg/dL
Calcium ≤ 8.6 mg/dL
Platelet count ≤ 300,000/μL
Elevated creatinine
Polymorphonuclear leukocyte count ≥80%
Presence of a focal infection

The risk of toxic shock syndrome is increased especially in children with erythroderma and fever who have the following additional features: age of 3 years or younger, ill appearance, elevated creatinine value, and hypotension upon arrival.

The disease course is gradual if it results from generalized spread of a primary skin disease (eg, psoriasis, atopic dermatitis).

The mean duration of illness typically is 5 years, with a median of 10 months.

Mortality varies according to the disease's cause. In a study of 91 of 102 patients with exfoliative dermatitis by Sigurdsson et al,^[43]a mortality of 43% was observed. Only 18% of the deaths were directly related to exfoliative dermatitis. In 74% of the deaths, causes unrelated to exfoliative dermatitis were implicated.

Next: Pathophysiology

Patient Education

Educate patients on the specifics of the underlying cause of their exfoliative dermatitis and the importance of diligent follow-up management as indicated. Patients should be educated on the benefits of a healthy lifestyle and to immediately treat occurrences of erythroderma to better manage their diseases in the long term. Patients should be advised to avoid the use of and/or contact with of irritant soaps, lotions, detergents, and chlorine, and special considerations should be made for allergies, especially for patients with atopic dermatitis.^[44]Excessive sweating should also be avoided.

For patient education resources, see Skin Conditions & Beauty Center and Life-Threatening Skin Rashes

Clinical Presentation

Al-Badawi S, Ahmed N, Akber M. Acute Exfoliative Dermatitis/Erythroderma Secondary to Gliclazide. Cureus. 2023 Sep. 15 (9):e45965. [QxMD MEDLINE Link]. [Full Text].
Yadav S, Hashmi MU, Shah S, Sarwar A, Ibrahim R. Correction: Vancomycin Flushing Syndrome Due to Oral Vancomycin in Chronic Kidney Disease Patients: A Case Report. Cureus. 2022 Oct. 14 (10):c79. [QxMD MEDLINE Link]. [Full Text].
Alvarez-Arango S, Ogunwole SM, Sequist TD, Burk CM, Blumenthal KG. Vancomycin Infusion Reaction - Moving beyond "Red Man Syndrome". N Engl J Med. 2021 Apr 8. 384 (14):1283-1286. [QxMD MEDLINE Link]. [Full Text].
Spicknall KE. Sézary syndrome-clinical and histopathologic features, differential diagnosis, and treatment. Semin Cutan Med Surg. 2018 Mar. 37 (1):18-23. [QxMD MEDLINE Link].
Verma P, Bhattacharya SN, Banerjee BD, Khanna N. Oxidative stress and leukocyte migration inhibition response in cutaneous adverse drug reactions. Indian J Dermatol Venereol Leprol. 2012 Sep-Oct. 78 (5):664. [QxMD MEDLINE Link].
Ohga Y, Bayaraa B, Imafuku S. Chronic idiopathic erythroderma of elderly men is an independent entity that has a distinct TARC/IgE profile from adult atopic dermatitis. Int J Dermatol. 2018 Jun. 57 (6):670-674. [QxMD MEDLINE Link].
Morozova EA, Olisova OY, Nikitin EA. Cutaneous manifestations of B-cell chronic lymphocytic leukemia. Int J Hematol. 2020 Oct. 112 (4):459-465. [QxMD MEDLINE Link].
Moerman-Herzog A, Mehdi SJ, Wong HK. Gene Expression Comparison between Sézary Syndrome and Lymphocytic-Variant Hypereosinophilic Syndrome Refines Biomarkers for Sézary Syndrome. Cells. 2020 Aug 29. 9 (9):[QxMD MEDLINE Link].
Plachouri KM, Georgiou S. Paraneoplastic erythroderma: an insight on the existing data. Int J Dermatol. 2020 Dec. 59 (12):1429-1436. [QxMD MEDLINE Link].
Mateo S, García-Martínez FJ, Sánchez-Aguilar D, Amarelo J, Toribio J. Psoriasiform exfoliative erythroderma induced by golimumab. Clin Exp Dermatol. 2014 Oct. 39 (7):813-5. [QxMD MEDLINE Link].
Doukaki S, Aricò M, Bongiorno MR. Erythroderma related to the administration of 99mTc-sestamibi: the first report. J Nucl Cardiol. 2010 Jun. 17 (3):520-2. [QxMD MEDLINE Link].
Rolfes N, Lümmen G. [Hypertension and palmar plantar erythroderma. Management of adverse events of angiogenetic inhibitors in the treatment of renal cell carcinoma]. Urologe A. 2011 Nov. 50 (11):1387-91. [QxMD MEDLINE Link].
Huang HY, Luo XQ, Chan LS, Cao ZH, Sun XF, Xu JH. Cutaneous adverse drug reactions in a hospital-based Chinese population. Clin Exp Dermatol. 2011 Mar. 36 (2):135-41. [QxMD MEDLINE Link].
Zhang B, Bolognia J, Marks P, Podoltsev N. Enhanced skin toxicity associated with the combination of clofarabine plus cytarabine for the treatment of acute leukemia. Cancer Chemother Pharmacol. 2014 Aug. 74 (2):303-7. [QxMD MEDLINE Link].
Zhang JC, Sun YT. Efavirenz-induced exfoliative dermatitis. Scand J Infect Dis. 2013 Jan. 45 (1):70-2. [QxMD MEDLINE Link].
Ram-Wolf C, Mahé E, Saiag P. Escitalopram photo-induced erythroderma. J Eur Acad Dermatol Venereol. 2008 Aug. 22 (8):1015-7. [QxMD MEDLINE Link].
Mumoli N, Luschi R, Camaiti A, Cei M, Bagnoni G, Biondi A. Severe exfoliative dermatitis caused by esomeprazole. J Am Geriatr Soc. 2011 Dec. 59 (12):2377-8. [QxMD MEDLINE Link].
Dua R, Sindhwani G, Rawat J. Exfoliative dermatitis to all four first line oral anti-tubercular drugs. Indian J Tuberc. 2010 Jan. 57 (1):53-6. [QxMD MEDLINE Link].
Lee HY, Tay LK, Thirumoorthy T, Pang SM. Cutaneous adverse drug reactions in hospitalised patients. Singapore Med J. 2010 Oct. 51 (10):767-74. [QxMD MEDLINE Link].
Reynaud F, Giraud P, Cisterne JM, Verdier D, Kouchakipour Z, Hermelin A, et al. [Acute immuno-allergic interstitial nephritis after treatment with fluindione. Seven cases]. Nephrol Ther. 2009 Jul. 5 (4):292-8. [QxMD MEDLINE Link].
Tamer E, Gur G, Polat M, Alli N. Flare-up of pustular psoriasis with fluoxetine: possibility of a serotoninergic influence?. J Dermatolog Treat. 2009. 20 (3):1-3. [QxMD MEDLINE Link].
Ozuguz P, Kacar SD, Ozuguz U, Karaca S, Tokyol C. Erythroderma secondary to gliclazide: a case report. Cutan Ocul Toxicol. 2014 Dec. 33 (4):342-4. [QxMD MEDLINE Link].
Hulmani M, Nandakishore B, Bhat MR, Sukumar D, Martis J, Kamath G, et al. Clinico-etiological study of 30 erythroderma cases from tertiary center in South India. Indian Dermatol Online J. 2014 Jan. 5 (1):25-9. [QxMD MEDLINE Link].
Kumar S, Mahajan BB, Kaur S, Banipal RP, Singh A. Imatinib mesylate induced erythroderma: A rare case series. J Cancer Res Ther. 2015 Oct-Dec. 11 (4):993-6. [QxMD MEDLINE Link].
Lunge S, Bhise R. Imatinib Mesylate Induced Erythroderma. J Assoc Physicians India. 2018 Dec. 66 (12):79-80. [QxMD MEDLINE Link].
Markvardsen LH, Jakobsen J. [Exfoliative dermatitis as a side effect of intravenous immunoglobulin treatment]. Ugeskr Laeger. 2011 Oct 24. 173 (43):2725-6. [QxMD MEDLINE Link].
Igawa K, Konishi M, Moriyama Y, Fukuyama K, Yokozeki H. Erythroderma as drug eruption induced by intravesical mitomycin C therapy. J Eur Acad Dermatol Venereol. 2015 Mar. 29 (3):613-4. [QxMD MEDLINE Link].
Choi CU, Rha SW, Suh SY, Kim JW, Kim EJ, Park CG, et al. Extensive exfoliative dermatitis induced by non-ionic contrast medium Iodixanol (Visipaque) used during percutaneous coronary intervention. Int J Cardiol. 2008 Feb 29. 124 (2):e25-7. [QxMD MEDLINE Link].
Vaish AK, Tripathi AK, Gupta LK, Jain N, Agarwal A, Verma SK. An unusual case of DRESS syndrome due to leflunomide. BMJ Case Rep. 2011 Sep. 2011:[QxMD MEDLINE Link].
Sadeghpour M, Bunick CG, Robinson DM, Galan A, Tigelaar RE, Imaeda S. Midodrine-induced acute generalized exanthematous pustulosis. Cutis. 2014 May. 93 (5):E17-20. [QxMD MEDLINE Link].
Arai S, Mukai H. Erythroderma induced by morphine sulfate. J Dermatol. 2011 Mar. 38 (3):288-9. [QxMD MEDLINE Link].
Bhandarkar AP, Kop PB, Pai VV. Nevirapine induced exfoliative dermatitis in an HIV-infected patient. Indian J Pharmacol. 2011 Nov. 43 (6):738-9. [QxMD MEDLINE Link].
Sánchez-Borges M, González-Aveledo L. Exfoliative erythrodermia induced by pantoprazole. Allergol Immunopathol (Madr). 2012 May-Jun. 40 (3):194-5. [QxMD MEDLINE Link].
Bilaç C, Müezzinoğlu T, Ermertcan AT, Kayhan TC, Temeltaş G, Oztürkcan S, et al. Sorafenib-induced erythema multiforme in metastatic renal cell carcinoma. Cutan Ocul Toxicol. 2009. 28 (2):90-2. [QxMD MEDLINE Link].
Smith EV, Shipley DR. Severe exfoliative dermatitis caused by strontium ranelate: two cases of a new drug reaction. Age Ageing. 2010 May. 39 (3):401-3. [QxMD MEDLINE Link].
Eyler JT, Squires S, Fraga GR, Liu D, Kestenbaum T. Two cases of acute generalized exanthematous pustulosis related to oral terbinafine and an analysis of the clinical reaction pattern. Dermatol Online J. 2012 Nov 15. 18 (11):5. [QxMD MEDLINE Link].
Nakamura M, Tokura Y. Tocilizumab-induced erythroderma. Eur J Dermatol. 2009 May-Jun. 19 (3):273-4. [QxMD MEDLINE Link].
Rowe CJ, Robertson I, James D, McMeniman E. Warfarin-induced erythroderma. Australas J Dermatol. 2015 Feb. 56 (1):e15-7. [QxMD MEDLINE Link].
Nishizawa A, Igawa K, Teraki H, Yokozeki H. Diffuse disseminated lichenoid-type cutaneous sarcoidosis mimicking erythroderma. Int J Dermatol. 2014 Aug. 53 (8):e369-70. [QxMD MEDLINE Link].
Sarkar R, Garg VK. Erythroderma in children. Indian J Dermatol Venereol Leprol. 2010 Jul-Aug. 76 (4):341-7. [QxMD MEDLINE Link].
Fraitag S, Bodemer C. Neonatal erythroderma. Curr Opin Pediatr. 2010 Aug. 22 (4):438-44. [QxMD MEDLINE Link].
Byer RL, Bachur RG. Clinical deterioration among patients with fever and erythroderma. Pediatrics. 2006 Dec. 118 (6):2450-60. [QxMD MEDLINE Link].
Sigurdsson V, Toonstra J, Hezemans-Boer M, van Vloten WA. Erythroderma. A clinical and follow-up study of 102 patients, with special emphasis on survival. J Am Acad Dermatol. 1996 Jul. 35 (1):53-7. [QxMD MEDLINE Link].
Lancrajan C, Bumbacea R, Giurcaneanu C. Erythrodermic atopic dermatitis with late onset--case presentation. J Med Life. 2010 Jan-Mar. 3 (1):80-3. [QxMD MEDLINE Link].
Yuan XY, Guo JY, Dang YP, Qiao L, Liu W. Erythroderma: A clinical-etiological study of 82 cases. Eur J Dermatol. 2010 May-Jun. 20 (3):373-7. [QxMD MEDLINE Link].
Jusufbegovic D, Char DH. Clinical variability of ocular involvement in mycosis fungoides. JAMA Ophthalmol. 2015 Mar. 133 (3):341-3. [QxMD MEDLINE Link].
Clark RA, Shackelton JB, Watanabe R, Calarese A, Yamanaka K, Campbell JJ, et al. High-scatter T cells: a reliable biomarker for malignant T cells in cutaneous T-cell lymphoma. Blood. 2011 Feb 10. 117 (6):1966-76. [QxMD MEDLINE Link].
Kirsch IR, Watanabe R, O'Malley JT, Williamson DW, Scott LL, Elco CP, et al. TCR sequencing facilitates diagnosis and identifies mature T cells as the cell of origin in CTCL. Sci Transl Med. 2015 Oct 7. 7 (308):308ra158. [QxMD MEDLINE Link].
Sbidian E, Battistella M, Rivet J, Flageul B, Molina JM, Joly P, et al. Remission of severe CD8(+) cytotoxic T cell skin infiltrative disease in human immunodeficiency virus-infected patients receiving highly active antiretroviral therapy. Clin Infect Dis. 2010 Sep 15. 51 (6):741-8. [QxMD MEDLINE Link].
Griffiths TW, Stevens SR, Cooper KD. Acute erythroderma as an exclusion criterion for idiopathic CD4+ T lymphocytopenia. Arch Dermatol. 1994 Dec. 130 (12):1530-3. [QxMD MEDLINE Link].
Bosseila M, Mahgoub D, El-Sayed A, Salama D, Abd El-Moneim M, Al-Helf F. Does fluorescence diagnosis have a role in follow up of response to therapy in mycosis fungoides?. Photodiagnosis Photodyn Ther. 2014 Dec. 11 (4):595-602. [QxMD MEDLINE Link].
Scrivener Y, Cribier B, Le Coz C, Boehm N, Jelen G, Heid E, et al. [Erythroderma with immunoglobulin deposits along the basal membrane. Pemphigoid erythroderma?]. Ann Dermatol Venereol. 1998 Jan. 125 (1):13-7. [QxMD MEDLINE Link].
Gros A, Laharanne E, Vergier M, Prochazkova-Carlotti M, Pham-Ledard A, Bandres T, et al. TP53 alterations in primary and secondary Sézary syndrome: A diagnostic tool for the assessment of malignancy in patients with erythroderma. PLoS One. 2017. 12 (3):e0173171. [QxMD MEDLINE Link].
Megna M, Sidikov AA, Zaslavsky DV, Chuprov IN, Timoshchuk EA, Egorova U, et al. The role of histological presentation in erythroderma. Int J Dermatol. 2017 Apr. 56 (4):400-404. [QxMD MEDLINE Link].
Ram-Wolff C, Martin-Garcia N, Bensussan A, Bagot M, Ortonne N. Histopathologic diagnosis of lymphomatous versus inflammatory erythroderma: a morphologic and phenotypic study on 47 skin biopsies. Am J Dermatopathol. 2010 Dec. 32 (8):755-63. [QxMD MEDLINE Link].
Ohga Y, Bayaraa B, Imafuku S. Therapeutic options and prognosis of chronic idiopathic erythroderma in older adults. Dermatol Ther. 2019 Jul. 32 (4):e12977. [QxMD MEDLINE Link].
Lee WK, Kim GW, Cho HH, Kim WJ, Mun JH, Song M, et al. Erythrodermic Psoriasis Treated with Golimumab: A Case Report. Ann Dermatol. 2015 Aug. 27 (4):446-9. [QxMD MEDLINE Link].
Wang J, Wang YM, Ahn HY. Biological products for the treatment of psoriasis: therapeutic targets, pharmacodynamics and disease-drug-drug interaction implications. AAPS J. 2014 Sep. 16 (5):938-47. [QxMD MEDLINE Link].
Sanford M, McKeage K. Secukinumab: first global approval. Drugs. 2015 Feb. 75 (3):329-38. [QxMD MEDLINE Link].
Liu LC, Jin XH, Sun C, Xia JX. Two cases of refractory erythrodermic psoriasis effectively treated with secukinumab and a review of the literature. Dermatol Ther. 2021 Mar. 34 (2):e14825. [QxMD MEDLINE Link].
Cole D, Mohammad T, Lim H. Rapid response of pityriasis rubra pilaris with psoriasis overlap to secukinumab. Br J Dermatol. 2019 Dec. 181 (6):1331-1332. [QxMD MEDLINE Link].
Alberti-Violetti S, Talpur R, Schlichte M, Sui D, Duvic M. Advanced-stage mycosis fungoides and Sézary syndrome: survival and response to treatment. Clin Lymphoma Myeloma Leuk. 2015 Jun. 15 (6):e105-12. [QxMD MEDLINE Link].
Cather JC, Crowley JJ. Use of biologic agents in combination with other therapies for the treatment of psoriasis. Am J Clin Dermatol. 2014 Dec. 15 (6):467-78. [QxMD MEDLINE Link].
Rosenbach M, Hsu S, Korman NJ, Lebwohl MG, Young M, Bebo BF Jr, et al. Treatment of erythrodermic psoriasis: from the medical board of the National Psoriasis Foundation. J Am Acad Dermatol. 2010 Apr. 62 (4):655-62. [QxMD MEDLINE Link].
Armstrong AW, Bagel J, Van Voorhees AS, Robertson AD, Yamauchi PS. Combining biologic therapies with other systemic treatments in psoriasis: evidence-based, best-practice recommendations from the Medical Board of the National Psoriasis Foundation. JAMA Dermatol. 2015 Apr. 151 (4):432-8. [QxMD MEDLINE Link].
Al Hothali GI. Review of the treatment of mycosis fungoides and Sézary syndrome: A stage-based approach. Int J Health Sci (Qassim). 2013 Jun. 7 (2):220-39. [QxMD MEDLINE Link].
Rupoli S, Canafoglia L, Goteri G, Leoni P, Brandozzi G, Federici I, et al. Results of a prospective phase II trial with oral low-dose bexarotene plus photochemotherapy (PUVA) in refractory and/or relapsed patients with mycosis fungoides. Eur J Dermatol. 2016 Jan-Feb. 26 (1):13-20. [QxMD MEDLINE Link].
Sokolowska-Wojdylo M, Florek A, Zaucha JM, Chmielowska E, Giza A, Knopinska-Posluszny W, et al. Polish Lymphoma Research Group Experience With Bexarotene in the Treatment of Cutaneous T-Cell Lymphoma. Am J Ther. 2016 May-Jun. 23 (3):e749-56. [QxMD MEDLINE Link].
Chung CG, Poligone B. Cutaneous T cell Lymphoma: an Update on Pathogenesis and Systemic Therapy. Curr Hematol Malig Rep. 2015 Dec. 10 (4):468-76. [QxMD MEDLINE Link].
Galper SL, Smith BD, Wilson LD. Diagnosis and management of mycosis fungoides. Oncology (Williston Park). 2010 May. 24 (6):491-501. [QxMD MEDLINE Link].
Wilcox RA. Cutaneous T-cell lymphoma: 2016 update on diagnosis, risk-stratification, and management. Am J Hematol. 2016 Jan. 91 (1):151-65. [QxMD MEDLINE Link].
Humme D, Nast A, Erdmann R, Vandersee S, Beyer M. Systematic review of combination therapies for mycosis fungoides. Cancer Treat Rev. 2014 Sep. 40 (8):927-33. [QxMD MEDLINE Link].
Hughes CF, Khot A, McCormack C, Lade S, Westerman DA, Twigger R, et al. Lack of durable disease control with chemotherapy for mycosis fungoides and Sézary syndrome: a comparative study of systemic therapy. Blood. 2015 Jan 1. 125 (1):71-81. [QxMD MEDLINE Link].
Duvic M, Olsen EA, Breneman D, Pacheco TR, Parker S, Vonderheid EC, et al. Evaluation of the long-term tolerability and clinical benefit of vorinostat in patients with advanced cutaneous T-cell lymphoma. Clin Lymphoma Myeloma. 2009 Dec. 9 (6):412-6. [QxMD MEDLINE Link].
Prince HM, Dickinson M, Khot A. Romidepsin for cutaneous T-cell lymphoma. Future Oncol. 2013 Dec. 9 (12):1819-27. [QxMD MEDLINE Link].
Foss F, Advani R, Duvic M, Hymes KB, Intragumtornchai T, Lekhakula A, et al. A Phase II trial of Belinostat (PXD101) in patients with relapsed or refractory peripheral or cutaneous T-cell lymphoma. Br J Haematol. 2015 Mar. 168 (6):811-9. [QxMD MEDLINE Link].
Guttman-Yassky E, Dhingra N, Leung DY. New era of biologic therapeutics in atopic dermatitis. Expert Opin Biol Ther. 2013 Apr. 13 (4):549-61. [QxMD MEDLINE Link].
Zattra E, Belloni Fortina A, Peserico A, Alaibac M. Erythroderma in the era of biological therapies. Eur J Dermatol. 2012 Mar-Apr. 22 (2):167-71. [QxMD MEDLINE Link].
Zackheim HS, Kashani-Sabet M, Hwang ST. Low-dose methotrexate to treat erythrodermic cutaneous T-cell lymphoma: results in twenty-nine patients. J Am Acad Dermatol. 1996 Apr. 34 (4):626-31. [QxMD MEDLINE Link].
Sigurdsson V, Toonstra J, van Vloten WA. Idiopathic erythroderma: a follow-up study of 28 patients. Dermatology. 1997. 194 (2):98-101. [QxMD MEDLINE Link].
Patel S, Patel T, Kerdel FA. The risk of malignancy or progression of existing malignancy in patients with psoriasis treated with biologics: case report and review of the literature. Int J Dermatol. 2016 May. 55 (5):487-93. [QxMD MEDLINE Link].
Hsu L, Armstrong AW. Anti-drug antibodies in psoriasis: a critical evaluation of clinical significance and impact on treatment response. Expert Rev Clin Immunol. 2013 Oct. 9 (10):949-58. [QxMD MEDLINE Link].

Media Gallery

Exfoliative dermatitis diffuse skin involvement.
Exfoliative dermatitis close-up view showing erythema and scaling.

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Table 1. Drugs Implicated in the Causation of Exfoliative Dermatitis

Table 1. Drugs Implicated in the Causation of Exfoliative Dermatitis

99mTC-sestamibi^[11]	ACE inhibitors	Allopurinol	Aminoglutethimide	Amiodarone
Amitriptyline	Amoxicillin	Ampicillin	Angiogenetic inhibitors^[12]	Arsenic
Aspirin	Atropine	Auranofin	Aurothioglucose	Barbiturates
Benactyzine	Beta-blockers	Beta carotene	Bumetanide	Bupropion
Butabarbital	Butalbital	Captopril	Carbamazepine	Carbidopa
Cephalosporins^[13]	Chloroquine	Chlorpromazine	Chlorpropamide	Cimetidine
Ciprofloxacin	Cisplatin	Clofarabine^[14]	Clofazimine	Clofibrate
Co-trimoxazole	Cromolyn	Cytarabine	Dapsone	Demeclocycline
Desipramine	Diazepam	Diclofenac	Diflunisal	Diltiazem
Doxorubicin	Doxycycline	Efavirenz^[15]	Enalapril	Escitalopram^[16]
Esomeprazole^[17]	Ethambutol^[18]	Etodolac	Fenofibrate^[19]	Fenoprofen
Fluconazole	Fluindione^[20]	Fluoxetine^[21]	Fluphenazine	Flurbiprofen
Furosemide	Gemfibrozil	Gliclazide^{[22, 1]}	Glipizide^[23]	Gold
Griseofulvin	Hydroxychloroquine	Imatinib^{[24, 25]}	Imipramine	Indomethacin
Intravenous immunoglobulin^[26]	Intravesical mitomycin C^[27]	Iodixanol^[28]	Isoniazid	Isosorbide
Ketoconazole	Ketoprofen	Ketorolac	Leflunomide^[29]	Lithium
Meclofenamate	Mefenamic Acid	Meprobamate	Methylphenidate
Midodrine^[30]	Minocycline	Morphine sulfate^[31]	Nalidixic Acid	Naproxen
Nevirapine^[32]	Nitrazepam^[23]	Nifedipine	Nitrofurantoin	Nitroglycerin
Nizatidine	Norfloxacin	Omeprazole	Pantoprazole^[33]	Penicillamine
Penicillin	Pentobarbital	Perphenazine	Phenobarbital	Phenothiazines
Phenylbutazone	Phenytoin	Piroxicam	Primidone	Prochlorperazine
Propranolol	Pyrazinamide^[18]	Pyrazolones	Quinapril	Quinidine
Quinine	Retinoids	Rifampin	Sorafenib^[34]	Streptomycin
Strontium ranelate^[35]	Sulfadoxine	Sulfamethoxazole	Sulfasalazine	Sulfisoxazole
Sulfonamides	Sulfonylureas	Sulindac	Terbinafine^[36]	Tetracycline
Tobramycin	Tocilizumab^[37]	Trazodone	Trifluoperazine	Trimethoprim
Vancomycin	Verapamil	Warfarin^[38]

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#author-disclosures{display:block}#author-disclosures.modal-layer{position:relative}#author-disclosures .modal-content{max-height:none}#author-disclosures .close-modal{display:none}

Author

Edward J Zabawski, Jr, DO, MBA Adjunct Assistant Professor, Clinical Sciences

Edward J Zabawski, Jr, DO, MBA is a member of the following medical societies: American Osteopathic Association, New England Dermatological Society, American Academy of Dermatology, Noah Worcester Dermatological Society, European Academy of Dermatology and Venereology

Disclosure: Nothing to disclose.

Specialty Editor Board

Rosalie Elenitsas, MD Herman Beerman Professor of Dermatology, University of Pennsylvania School of Medicine; Director, Penn Cutaneous Pathology Services, Department of Dermatology, University of Pennsylvania Health System

Rosalie Elenitsas, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, American Society of Dermatopathology, Pennsylvania Academy of Dermatology

Disclosure: Received royalty from Lippincott Williams Wilkins for textbook editor.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

James W Patterson, MD Professor of Pathology and Dermatology, Director of Dermatopathology, University of Virginia Medical Center

James W Patterson, MD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, American Society of Dermatopathology, Royal Society of Medicine, Society for Investigative Dermatology, United States and Canadian Academy of Pathology

Disclosure: Nothing to disclose.

Sanusi H Umar, MD, FAAD Clinical Instructor of Medicine, Department of Medicine, Division of Dermatology, University of California, Los Angeles, David Geffen School of Medicine

Sanusi H Umar, MD, FAAD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, American Medical Association

Disclosure: Nothing to disclose.

A Paul Kelly, MD Chief, Clinical Professor, Department of Internal Medicine, Division of Dermatology, King/Drew Medical Center, Charles Drew University of Medicine and Science

A Paul Kelly, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, National Medical Association, Pacific Dermatologic Association

Disclosure: Nothing to disclose.

Sections Erythroderma (Generalized Exfoliative Dermatitis)
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Erythroderma (Generalized Exfoliative Dermatitis)

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