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7/13/2019 ERYTHRODERMA
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ERYTHRODERMA
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Complaints-usually redness,itching, sense of
tightness and fever
History present illness-
duration,progression,history of remissions and
exacerbations
History related to etiology-itching,fever,type of
scaling,vesicles and bulla
h/o joint pain
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H/o Medications
H/o Atopy
H/o loss of weight and appetite
H/o photosensitivity,muscle weakness
H/o bleeding tendency.
h/o previous infection ( dermatophyte,scabies)
h/o organ transplantation
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H/o related to complications of erythroderma
H/o difficulty in
breathing,palpitation,diarrhoea
H/o fever,chills,skin infections
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Personal history:
Occupation-contact with cement,plants
Marital history,sexual history Smoking and alcohol abuse
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FAMILY HISTORY
Skin disease-ichthyosis,atopy,scabies
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General examination:
temperature,pulse rate,respiratory
rate,CVS,RS,Abdomen,PV,PR,lymph nodes
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Dermatological examination
look for any clues to etiology-like
plaques,papules,vesicles,burrow,
Hair,Nails, oral mucosa
genitals
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Bedside investigations
Scraping for fungus,scabies
Nikolsky sign,Asboe Hansen sign Peripheral smear
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ERYTHRODERMA/EXFOLIATIVE
DERMATITIS
HISTORY:
Hebra -1868
Wilson Brocq-chronic relapsingHebra-progressing
Savil-self limited
Males affected more commonly-2-4 times
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Causes of erythroderma in adults
Hereditary disorders
Ichthyosiform erythroderma,pityriasis rubrapilaris,Psoriasis,Reiters,seborrhoeic dermatitis
Eczemas of various types-atopic,venouseczema,chronic actinic dermatitis
Drugs-arsenic,gold,mercury,pencillin,barbiturates,carbamazepine,cimetidine,lithium,allopurinol,antimalarials,cephalospirins,sulphonamides,dapsone,phenobarbitone,phenybutazone,asprin,catopril,INH,
SM,Vitamin A
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Bullous disorders-pemphigus foliaceous
Lymphomas and leukaemias
OTHER SKIN DISEASES Lichen planus
Dermatophytosis-trichophyton violaceum
Crusted scabies dermatomyositis
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UNKNOWN
RARE CAUSES
Sarcoidosis,Hailey-hailey,pemphigoid,toxicshock syndrome,LE,angioimmunoblasticlymadenopathy,GVHD
carcinoma lungs,carcinoma rectum,multiplemyeloma,mycosis fungoides,reticulum cellsarcoma
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Erythroderma in neonates and infants
1)ICHTHYOSIS:NBIE,BIE,Nethertonsyndrome,Conradi Hunermannsyndrome,lamellar
ichthyosis,Trichothiodystrophy 2)INFECTIONS-SSSS,scarlet fever,neonatal
candidiasis,toxic shock syndrome
3)INFESTATIONS-Norwegian scabies 4)IMMUNODEFICIENCY-Omenns
syndrome,GVHD
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5)DRUG INDUCED:ceftroxone,vancomycin,antiepileptics,sulphonamides,antitubercular drugs,homeopathic and indigenousmedicines
6)METABOLIC/NUTRITIONALDisorders of biotin metabolism,EFAdeficiency,kwashiokar,acrodermatitisenteropathica,cystic fibrosis,Leinersdisease,multiplecarboxylase deficiency
7)OTHER DISORDERS:infantile seborrhoeicdermatitis,atopic dermatitis,psoriasis,PRP,diffusecutaneous mastocytosis
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Causes of erythroderma in preschool
and school going children
1)Ichthyosis
2)Atopic dermatitis
3)Infestations-norwegian scabies 4)papulosquamous diorder-psoriasis,PRP
5)Drugs-
antiepileptics,sulphonamides,antituberculardrugs,homeopathic and indigenous medicines
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6)Metabolic/nutritional-
kwashiorkar,acrodermatitis enterpathica,cystic
fibrosis,cutaneous T cell lymphoma
7)Miscellaneous and rare disorders
Kwashiorkar
disease,dermatomyositis,sarcoidosis,
Pemphigus
8)idiopathic
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Causes of erythroderma in AIDS
1)seborrhoeic dermatitis
2)lymphoma
3)drug induced erythroderma
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Dermatological manifestations
Starts as erythematous patches-
Covers entire skin in days to weeks
Bacterial colonisation-crusting Chronic-induration,thickening and
lichenification
Clues of previous skin disease may be found
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Erythroderma of eczema and lymphoma-sudden onset,intensity may fluctuate overperiods.
Irritation may be severe and sense oftightness
Venous eczema-6 or 7 decade
Atopic eczema-any agePruritus often intense.Increased Ig E andeosinophilia
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Psoriatic erythroderma-features of psoriasis
often lost.Miliary pustules may develop
Stress,intercurrent illness,drugs,phototherapy
Pemphigus foliaceous-thin walled vesicles
PRP-childhood or adult.Islands of normal skin
persist even in erythroderma.horny plugs-maybe seen.palms and soles-orange
discolouration
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Drug induced erythroderma
start in flexures or whole skin
Scarlatiniform or morbilliform rash
Nails- shore line nails Best prognosis-resolves in 2-6 weeks
DRESS SYNDROME-drug reaction with
eosinophilia and systemic symptoms.
Erythroderma in lymphoma and
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Erythroderma in lymphoma and
leukaemia
Pruritus is often severe,secondary
lichenification.
Erythrodermauniversal
Lymph nodes,hepatosplenomegaly
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Lichen planus-after erythema subsides-
violaceous papules.
Mucosa-bluish white streaks
Norwegian scabies-generalised with
involvement of face and palms
H/oitching in contacts
Dermatomyositis-gottronspapules,muscle
weakness,heliotrope rash
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RED MAN SYNDROME
Chronic erythroderma of unknown origin in
elderly men.
Long course
PPK,dermopathic lymphadenopathy,increased
serum Ig E.
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Papuloerythroderma of Ofugi
Elderly men
Flat topped papules-plaques
Deck chair sign
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Nail changes
Thickened,ridged,dull and brittle
Subungual hyperkeratosis,onycholysis,splinter
haemorrage
Beaus lines
Shoreline nails
Shiny nails-constant itching
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Palmoplantar keratoderma
Mucosa-usually not involved.
Generalised vitiligo,disseminated pyogenicgranuloma,anhidrosis,xanthoma,pigmentary
changes-after resolution
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Systemic associations
1)axillary and inquinal lymadenopathy-
dermatopathic lymphadenopathy-62%
2)Hepatosmegaly-37%
3)splenomegaly-23%
4)Poikilothermia
5)increased transepidermal water loss
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Vascular changes-tachycardia,high output
cardiac failure,right sided heart failure,IHD
Increased BMR,loss of weight
Renal insufficiency
Protein loss and negative nitrogen balance
Pulmonary capillary leak syndrome & ARDS
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Gynaecomastia
Anaemia
GIT-malabsorption
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LAB INVESTIGATIONS
Complete haemogram-Hb,eosinophils,ESR
Peripheral smear,Tzanck
Motion for occult blood
X-ray chest,ECG
USG abdomen
Serum electrolytes,creatinine
LDH
LFT-protein level
Blood glucose
Gamma globulin,Ig E
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SKIN BIOPSY
LYMPHNODE BIOPSY
IMMUNOFLOURESCENCE.
IMMUNOHISTOCHEMISTRY
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IN CHILDREN
Complete blood count,hair mount,grams stain
Immunoglobulin assay,sweat chloride levels
Zinc and alkaline phosphatase levels
Biotinidase and holocarboxylase and EFA
Gene analysis-SPINK-5
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HISTOPATHOLOGY IN ERYTHRODERMA
Diagnostic value is conflicting-50%
Multiple biopsy
Useful in T-cell related erythroderma
Nonspecific,subacute and chronic spongiotic
dermatitis.
Drug related erythroderma Psoriatic erythroderma-early lesions of
psoriasis
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Prognosis and complications
Serious condition.Elderly patients-prognosis
guarded.
Erythroderma due to psoriasis and eczema-
may continue for months and years.
Good prognosis-drug induced erythroderma
Hypothermia,cardiac
decompensation,peripheral circulatory
failure,respiratory infection.
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MANAGEMENT
Admission
Maintenance of environmental temperature
Fluid-intake output chart
Urea electrolyte balance-monitored
Protein diet and folate supplementation
Bland emollients,soaks,compresses
Topical steroid.
Antihistamines and antibiotics
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Treatment of underlying cause
Psoriasis-
cyclosporine,methotrexate,acitretin,MMF
PRP-Retinoids,steroids,
Drug reaction-steroids,immunoglobulins
T-cell lymphoma-steroids,electron beamtherapy,chrorambucil
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To summarise
Idiopathic-25%
Psoriasis-23%
Eczema-16%
Cutaneous T-cell lymphoma-16%
Drug reaction-15%
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THANK YOU