Acute conditions in dermatology: toxic reactions and their treatment

Acute severe conditions caused by the use of various drugs are of particular difficulty in dermatological practice. Toxicodermic reactions include DRESS syndrome, StevensJohnson syndrome, toxic epidermal necrolysis, acute generalized exanthematous pustulosis and erythroderma of various origins. These disorders are characterized not only by skin lesions, but also toxic reactions in internal organs, which if untreated properly can be life-threatening. The first choice drugs for such reactions are systemic glucocorticosteroids, in particular betamethasone derivatives. Our own experience and numerous studies confirm the effectiveness of such drugs. However, it should be remembered that uncontrolled or prolonged use of systemic glucocorticosteroids can aggravate the patient's condition and lead to unwanted adverse reactions.

Erythroderma: a prospective study of 309 patients followed for 12 years in a tertiary center

Erythroderma is characterized by erythema and scaling affecting more than 80% of the body surface area. It is potentially life-threatening, and diagnosis of the underlying disease is a challenge. Despite laboratory improvements, many cases remain idiopathic. We aimed to analyze clinical and laboratory findings of 309 erythrodermic patients to find clues to the etiologic diagnosis. We performed a prospective study at the University of São Paulo Medical School, from 2007 to 2018, with patients with acquired erythroderma. Clinical, laboratory, histology, and molecular biology data were collected. The median age at diagnosis was 57 years, with a male-to-female ratio of 2.2. Eczema was the most frequent etiology (20.7%), followed by psoriasis (16.8%), Sézary syndrome (12.3%), drug eruption (12.3%), atopic dermatitis (8.7%), and mycosis fungoides (5.5%). Other diagnoses (6.8%) included pemphigus foliaceous, paraneoplastic erythroderma, adult T-cell leukemia/lymphoma, dermatomyositis, pityriasis rubra pilaris, lichen planus, bullous pemphigoid, and leprosy. In 52 patients (16.8%), it was not possible to elucidate erythroderma etiology. Atopic dermatitis developed erythroderma at an earlier age (median 25 years; P = 0.0001). Acute onset was associated with drug reactions and atopic dermatitis (median time from erythroderma to diagnosis of 1 and 1.5 months, respectively; P = 0.0001). Higher immunoglobulin E levels were observed in atopic dermatitis (median 24,600 U/L; P = 0.0001). Histopathology was helpful and was consistent with the final diagnosis in 72.4%. Monoclonal T-cell proliferation in the skin was observed in mycosis fungoides (33.3%) and Sézary syndrome (90.9%). At the last assessment, 211 patients (69.3%) were alive with disease, 65 (21.7%) were alive without disease, and 27 (9.1%) died with active disease. Erythroderma is a challenging syndrome with a difficult diagnostic approach. Younger age and higher immunoglobulin E levels are associated with atopic dermatitis; acute onset is observed in drug eruptions and atopic dermatitis. Histopathology and molecular biology tests are essential tools in the investigation of erythroderma.

Erythroderma as a paraneoplastic manifestation of small cell lung cancer

Erythroderma is a rare clinical entity characterized by generalized erythema affecting the whole or most of the body's skin surface. It is associated with a variety of underlying conditions, including preexisting dermatoses, infections, connective tissue disorders, drugs, malignancies, or it may be idiopathic. A case of a 73-year-old man, with a 5-month history of erythroderma, eventually diagnosed with small cell lung cancer is presented. This is the first reported case indicating an association between erythroderma and small cell lung cancer, extending, thus, current knowledge regarding small cell lung cancer-related paraneoplastic manifestations as well as erythroderma's causative factors.

Adverse Drug Reactions

Adverse events and adverse drug reactions are common in clinical practice. Side effects range from the common to the rare and may be confused with other mucocutaneous manifestations resulting from several medications to treat infections, other medical conditions, and in the clinical setting of oncologic treatment. The objective of this chapter to review current data on adverse drug reactions, here classified as (i) severe adverse drug reactions, (ii) uncomplicated cutaneous adverse drug reactions, and (iii) adverse drug reactions caused by chemotherapy drugs, particularly those cases whereby the dermatologist is requested to issue a report and asked to comment on the safety and viability of readministration of a specific drug. We describe aspects associated with these events, presenting a detailed analysis of each of them.

The role of histological presentation in erythroderma

BACKGROUND

Erythroderma is a serious medical condition characterized by inflamed red skin involving over 90% of the body. It can be the common presentation of different diseases, therefore clinical diagnosis can be problematic. Controversial data are reported regarding the diagnostic value of histological examination in erythroderma subjects.

METHODS

A retrospective study was performed, investigating histological skin specimens of patients with a clinical diagnosis of erythroderma admitted to the Department of Dermatology of State Pediatric Medical University, Saint Petersburg, from 2001 to 2014. Histopathology examination was performed in each case by a pathologist with a special interest in the skin disease who was blind to any clinical information as well as to final diagnosis.

RESULTS

Blinded histopathology examination alone was able to give the correct diagnosis in 61% (n = 50/82) of cases when compared to final diagnosis. A diagnosis of psoriasis was made in 23.2% (n = 19/82) of subjects, spongiotic dermatitis/eczema in 20.7% (n = 17/82), mycosis fungoides in 8.5% (n = 7/82), and drug eruption in 8.5%; histological diagnosis was inconclusive or not matching the final diagnosis when available in the remaining 39.1% of cases (n = 32/82).

CONCLUSION

Erythroderma remains a condition difficult to study and treat. We showed that a correct judgment about its cause can be based on objective histopathological criteria in up to 60% of cases. More studies are needed to try to find out further histological and/or immunohistochemical markers that could help the clinician with the erythroderma etiology diagnostic process.

Erythroderma secondary to gliclazide: a case report

Erythroderma is generalized exfoliative dermatitis, which involves more than 90% of the patient's skin. The most common cause of erythroderma is exacerbation of an underlying skin disease, malignancies or drug reaction. There is a long list of drugs responsible for erythroderma such as antiepileptics, sulfonamides, antibiotics, and angiotensin converting enzyme (ACE) inhibitors. We herein report a case of erythroderma due to gliclazide usage which is also proved by histopathologic examination and patch test. We could not find any case report of gliclazide, an oral antidiabetic, as a cause erythroderma in the literature.

Neonatal and infantile erythroderma: a clinical and follow-up study of 42 cases

Erythroderma in neonates and infants is a frequently encountered problem in the daily practice of pediatric dermatology. The objective of this study was to determine the frequency of various causes of this clinical entity, as well as which clinical and laboratory findings are useful in the differentiation of these causes, and to assess the evolution of this disease in this age group. Forty-two patients with erythroderma under 1 year of age were included in this study. A follow-up period of 3-5 years was completed. The study was performed in the Department of Dermatology, Al-Sadr and Alhakeem teaching hospitals and a private section in Najaf governorate, Iraq during the period 1998-2006. The diagnosis was made at an average of 3 months after the onset of the disease. The underlying causes included seborrheic dermatitis in 21.4%, atopic dermatitis in 14.3%, different types of Ichthyoses in 31.5%, psoriasis in 4.7%, pityriasis rubra pilaris in 2.4%, Staphylococcal scalded skin syndrome in 7.14%, Netherton syndrome in 4.7%, immune deficiency syndromes in 4.8% and undetermined erythroderma in 9.5% of the patients. Of 29 cases, histopathological examination of skin biopsy showed non-specific features in 58.7% and could confirm the diagnosis in 41.3% cases. The prognosis was poor with a mortality rate of 26.2% and severe dermatoses persisted in 60% of the survivors. It is difficult to make the etiological diagnosis of neonatal erythroderma from the first examination. Associated immune deficiency should be suspected if the condition associated with skin indurations, severe alopecia, failure to thrive and/or have infectious complications. The prognosis is poor especially in those with immune deficiency or a chronic persistent course.

Dermatite esfoliativa: estudo clínico-etiológico de 58 casos

FUNDAMENTO: Dermatite esfoliativa é síndrome cutânea caracterizada por eritema e descamação generalizados, que pode ser conseqüente ou estar associada a várias doenças dermatológicas prévias, doenças sistêmicas ou reações medicamentosas. OBJETIVOS: Relatar a freqüência das diferentes causas e características clínicas associadas à dermatite esfoliativa nos pacientes atendidos no Setor de Dermatologia do Hospital Universitário Regional do Norte do Paraná, da Universidade Estadual de Londrina. MÉTODOS: Foram revisados os registros de pacientes com diagnóstico de dermatite esfoliativa diagnosticados no Hospital Universitário Regional do Norte do Paraná no período de 10 anos. RESULTADOS: Foi encontrado o total de 58 pacientes com diagnóstico de dermatite esfoliativa, com idade média de 56,89 anos. Em 33 pacientes, foi definida uma dermatose como causa (psoríase, 11 casos; dermatite de contato, nove casos; eritrodermia ictiosiforme congênita, três casos; dermatite seborréica, cinco casos; dermatite atópica, três casos; pitiríase rubra pilar, dois casos). Reações a drogas foram observadas em 11 pacientes. Em 14 casos (24%) não foi possível determinar a causa básica. CONCLUSÕES: Numa amostra de pacientes atendidos num serviço de referência em dermatologia, a dermatite esfoliativa foi ocorrência pouco comum, e a maior parte dos casos estava relacionada a doenças dermatológicas.

On the diagnosis of erythrodermic cutaneous T-cell lymphoma

Erythrodermic cutaneous T-cell lymphoma (E-CTCL) is the cause of less than 5% of all cases of generalized erythroderma. A methodical evaluation of skin, blood, and lymph node samples using standard histology, immunohistochemistry (IHC), flow cytometry (FC), and molecular analysis for evidence of a dominant T-cell clone has been recommended in a recently published diagnostic algorithm. In this commentary, the author discusses available information regarding the role of these diagnostic methods for the diagnosis of E-CTCL with emphasis on personal observations regarding skin IHC and polymerase chain reaction (PCR)-based molecular studies as adjunct diagnostic studies on a series of 55 patients with erythrodermic mycosis fungoides and 50 patients with Sézary syndrome compared to 50 patients with extensive benign inflammatory skin disease. The conclusions are (1) IHC of the skin does not reliably differentiate E-CTCL from benign simulants, (2) presence of phenotypically abnormal T cells in the blood or expanded subsets of CD4+CD7- or CD4+CD26- cells by FC is particularly helpful as a diagnostic study, (3) the presence of an identical T-cell clone in the skin and blood also is a specific diagnostic criterion for E-CTCL, but exceptions may occur, and (4) the PCRgamma-denaturing gradient gel electrophoresis technique appears to be more reliable than PCRgamma-single-stranded conformational polymorphism for diagnostic purposes.

Erythroderma in adults: a report of 80 cases

BACKGROUND

Erythroderma is a generalized erythema of the skin accompanied by a variable degree of scaling. However, most of the published series originate from Western countries. There is only one report from Africa, conducted in Dakar in 1979. The aim of our study was to provide information about this condition in our country.

PATIENTS AND METHODS

Our study was retrospective, dealing with 80 erythrodermic adults, examined between January 1981 and December 2000. Patient information included clinical, laboratory, histopathologic and therapeutic data. We also noted patients' outcomes within an average follow-up period of 30 months. Thus, we calculated the mortality rate and estimated the probability of survival without relapses according to the Kaplan-Meier method.

RESULTS

The frequency of erythroderma in our dermatology department was 0.3. The sex ratio (male/female) was 2.2. The average age of our patients was 53.78 +/- 18 years. Previous history of skin disease was found in 49/80 patients (61.2%) and 32 of them were suffering from psoriasis. Hyperthermia was significantly associated with drug reactions (P = 0.013). Hypereosinophilia was not a specific finding. The mortality rate was higher than that of an age-matched population.

CONCLUSION

Adult erythroderma is a rare condition. Its most common cause in our study was psoriasis. No cases of atopic dermatitis were found. Prognosis was adversely affected by the presence of erythroderma.

Erythroderma: a clinical study of 97 cases

Background

Erythroderma is a rare skin disorder that may be caused by a variety of underlying dermatoses, infections, systemic diseases and drugs.

Methods

We reviewed the clinical, laboratory and biopsy material of 97 patients diagnosed with erythroderma who were treated in our department over a 6-year period (1996 through 2002).

Results

The male-female ratio was 1.85:1. The mean age at diagnosis was 46.2 years. The most common causative factors were dermatoses (59.7%), followed by drug reactions (21.6%), malignancies (11.3%) and idiopathic causes (7.2%). Carbamazepine was the most common drug (57.1%). The best clinicopathologic correlation was found in cutaneous T-cell lymphoma and pityriasis rubra pilaris related erythroderma. Apart from scaling and erythema that were present in all patients, pruritus was the most common finding (97.5%), followed by fever (33.6%), lymphadenopathy (21.3%), edema (14.4%) and hyperkeratosis (7.2%).

Conclusion

This study outlines that underlying etiologic factors of erythroderma may show geographic variations. Our series had a high percentage of erythroderma secondary to preexisting dermatoses and a low percentage of idiopathic cases. There was no HIV-infected patient among our series based on multiple serum antibody tests. The clinical features of erythroderma were identical, irrespective of the etiology. The onset of the disease was usually insidious except in drug-induced erythroderma, where it was acute. The group associated with the best prognosis was that related to drugs.

Life-threatening erythroderma: diagnosing and treating the “red man”

Exfoliative erythroderma, or diffuse erythema and scaling of the skin, may be the morphologic presentation of a variety of cutaneous and systemic diseases. Establishing the diagnosis of the underlying disease is often difficult and, not uncommonly, erythroderma is classified as idiopathic. Several cases are presented to demonstrate the diversity of presentation of this disease. Laboratory findings are typically unhelpful in establishing the etiology of erythroderma. Clinical data combined with multiple skin biopsies over time are necessary. Systemic complications of erythroderma include infection, fluid and electrolyte imbalances, thermoregulatory disturbance, high output cardiac failure, and acute respiratory distress syndrome. The initial approach to the management of erythroderma of any etiology includes attention to nutrition, fluid and electrolyte replacement, and the institution of gentle local skin care measures. Oatmeal baths and wet dressings to weeping or crusted sites should be followed by application of bland emollients and low-potency topical corticosteroids. Systemic dermatologic therapy may be required to maintain improvement achieved with local measures or to control erythroderma refractory to local measures. The prognosis of erythroderma is dependent on the underlying etiology.

Reações cutâneas graves adversas a drogas - aspectos relevantes ao diagnóstico e ao tratamento - Parte I - Anafilaxia e reações anafilactóides, eritrodermias e o espectro clínico da síndrome de Stevens-Johnson & necrólise epidérmica tóxica (Doença de Lyell)

As reações cutâneas graves adversas a droga (RCGAD) são as que geralmente necessitam de internação hospitalar, por vezes em unidade de terapia intensiva ou de queimados, com observação minuciosa dos sinais vitais e da função de órgãos internos. O objetivo é descrever essas reações, facilitando seu reconhecimento e tratamento. Fazem parte desse grupo a anafilaxia, a síndrome de Stevens-Johnson (SSJ), a necrólise epidérmica tóxica (NET) e, dependendo do envolvimento sistêmico, as eritrodermias. Neste artigo, são abordados as características clínicas e o tratamento de algumas reações adversas a droga: anafilaxia, as eritrodermias, a síndrome de Stevens-Johnson (SSJ) e a necrólise epidérmica tóxica (NET).

Progress in the understanding of the pathology and pathogenesis of cutaneous drug eruptions : implications for management

Cutaneous drug eruptions are among the most common adverse reactions to drug therapy. The etiology may reflect immunologic or nonimmunologic mechanisms, the former encompassing all of the classic Gell and Combs immune mechanisms. Cumulative and synergistic effects of drugs include those interactions of pharmacokinetic and pharmacodynamic factors reflecting the alteration by one drug of the effective serum concentration of another and the functions of drugs and their metabolites that interact to evoke cutaneous and systemic adverse reactions. Recent observations include the role of concurrent infection with lymphotropic viruses and drug effects that, through the enhancement of lymphoid blast transformation and/or lymphocyte survival and the contribution of intercurrent systemic connective tissue disease syndromes, promote enhanced lymphocyte longevity and the acquisition of progressively broadening autoantibody specificities. The latter are particularly opposite to drug-induced lupus erythematosus and to drug reactions in the setting of HIV infection. Specific common types of cutaneous drug eruptions will be discussed in this review. Successful management of cutaneous drug eruptions relies upon the prompt discontinuation of the causative medication; most drug eruptions have a good prognosis after this is accomplished. Oral or topical corticosteroids can be administered to aid in the resolution of some types of eruptions. Antihistamines or anti-inflammatory agents may also be administered for some eruptions.

Adult-onset recalcitrant eczema: a marker of noncutaneous lymphoma or leukemia

BACKGROUND

Generalized eczema or erythroderma may be the presenting sign of cutaneous T-cell lymphoma. Additionally, intractable pruritus has been associated with Hodgkin's lymphoma. However, reports of adult-onset eczematous dermatitis has rarely been linked to noncutaneous lymphoproliferative disorders.

OBSERVATIONS

We observed one patient in 1993 who had the onset of intractable dermatitis characterized by prurigo nodularis-like lesions and widespread erythematous plaques. After 18 months of cutaneous symptoms he experienced dyspnea. At this time Hodgkin's disease was diagnosed. This observation prompted us to evaluate subsequent patients with adult-onset eczema who were poorly responsive to therapy and in whom an obvious cause could not be determined. Over the next 24 months we identified an additional 2 patients with lymphoma who met this criteria.

CONCLUSION

Unexplained eczema of adult onset may be associated with an underlying lymphoproliferative malignancy. When a readily identifiable cause (eg, contactants, drugs, or atopy) is not found, a systematic evaluation should be pursued. Patients should be evaluated with a careful physical examination, complete blood cell counts, peripheral blood smears, chest roentgenography, computed tomography of the chest and abdomen, and serum protein electrophoresis.

Erythroderma

Erythroderma can be caused by a variety of underlying dermatoses, infections, and systemic diseases. Many of the findings on history, physical examination, and laboratory evaluation are nondiagnostic. Distinctive clinical and laboratory features pointing to a specific disease may be evident, however. Conclusive clinicopathologic correlation may require multiple and repeated skin biopsies. The prognosis of erythroderma has improved with the advent of innovative dermatologic therapies (e.g., cyclosporine and synthetic retinoids) and advances in the management of systemic manifestations. Death from sepsis, cardiac failure, adult respiratory distress syndrome, and capillary leak syndrome continue to be rarely reported. A high index of suspicion for these complications must be maintained to facilitate early medical intervention.

Pityriasis rubra pilaris (PRP): report of four cases

Four patients with pityriasis rubra pilaris are reported. The diagnosis in each was based upon well-recognized clinical features. Two of them, a mother and son, had the disease since childhood and were marked by relative remission in spring and exacerbation in autumn. Moderate to severe pruritus was a common dominator. Erythroderma was a presenting feature in one case. Although histopathology was considered imperative, it only supplemented the clinical expression. Vitamin A in heavy dosage, supplemented by vitamin E and stanozolol in tandem, was the mainstay of treatment.

Erythroderma: a comparison between HIV positive and negative patients

Background Erythroderma has protean underlying causes. There have been isolated case reports suggesting an association between erythroderma and the human immunodeficiency virus (HIV).

OBJECTIVE

To describe and characterize further the prevalence, etiology, and metabolic sequelae of erythroderma in HIV positive and negative patients. In a subset of patients, clinicopathologic correlation was performed.

METHOD

One hundred and thirty-eight consecutive patients were prospectively recruited over a one and a half year period at the skin clinic of King Edward VIII Hospital. Demographic, clinical, biochemical, and histologic data were recorded.

RESULTS

Seventy-five per cent of the patients were black, 22.5% Indian, and 2.5% white. The men to women ratio was 1.9 : 1. The mean age was 34. 7 years (range, 1 month to 85 years). Forty-three per cent of patients were HIV positive, of whom 90% were black. The commonest causes of erythroderma in the total sample were atopic dermatitis (23.9%), psoriasis (23.9%), and drug reactions (22.5%). The commonest cause in the HIV positive group was drug reactions (40.6%), the commonest being ethambutol (30.8%). HIV positive patients had a significantly lower (P < 0.05) white cell count (7.6 vs. 10.5 x 109 /L), hemoglobin (11.1 vs. 12.6 g/dL), platelets (278.3 vs. 378.0 x 109 /L), and albumin (25.4 vs. 28.7 g/L) and significantly higher serum urates (0.6 vs. 0.4 mM/L) than HIV negative patients. HIV positive patients did not have a significant increase in the number of episodes of erythroderma. Clinicopathologic correlation was greatest with psoriasis in the HIV negative group and with psoriasis and drug reactions in the HIV positive group.

CONCLUSIONS

A large proportion of erythrodermic patients in this study were HIV positive. Inflammatory dermatoses were the commonest cause of erythroderma in all the patients studied. Drug reactions were the commonest cause in HIV positive patients. In the young black patient, erythroderma may be a marker for HIV infection.

Erythroderma in children: a clinico-etiological study

Although there are various published studies on erythroderma from western and Asian countries, most of them have only included patients in the adult age groups. As we have an exclusively pediatric dermatology unit, we thought it would be intriguing to study the clinical, etiological and laboratory parameters of erythroderma in children. Seventeen erythroderma patients of both sexes were inducted into the study between 1993 to 1998. The mean age of onset was 3.3 years and the male:female ratio was 0.89:1. Eight (47%) of the patients were infants; 9 (53%) others belonged to the preschool and school going age group (age range between 1 to 12 years). An acute onset of the disease was seen in 47% of the patients while 53% of the patients had a chronic onset. The main presenting complaints were itching in 41% and burning in 18% of patients. Scalp involvement (71%), nail involvement (18%), and alopecia (6%) were the main cutaneous features observed while fever (53%), tachycardia (53%), pedal edema (12%), lymphadenopathy (18%), and hepatomegaly (12%) were the main systemic features observed in this study. Etiologically, drugs (29%), showed the highest incidence, followed equally (18%) by genodermatoses, psoriasis, and staphylococcal scalded skin syndrome (SSSS). Two (12%) patients had erythroderma due to atopic dermatitis, while one was (5%) due to infantile seborrheic dermatitis coexisting with dermatophytosis. Laboratory parameters contributed little towards diagnosis of the underlying dermatological condition. Thus, though erythroderma is a striking entity, it is yet uncommon in the pediatric age group. Because the drug induced group was the largest in this study, we recommend that drugs should be suspected as important causative factors of erythroderma in children.

Erythroderma. A clinical and follow-up study of 102 patients, with special emphasis on survival

BACKGROUND

Erythroderma may result from different causes. There have been no publications on this subject with special emphasis on survival.

OBJECTIVE

The aim of the study was to determine the cause of the erythroderma and the prognosis of these patients.

METHODS

Clinical and follow-up data from 102 patients with erythroderma were analyzed. We estimated survival of patients with erythroderma, from causes other than Sézary syndrome, mycosis fungoides, or leukemia cutis. The survival was compared with that of an age-matched control group of the general population.

RESULTS

The main cause of erythroderma was exacerbation of a preexisting dermatosis (53%). Drug reactions were rarely the cause (5%). A high proportion of the patients had chronic actinic dermatitis/actinic reticuloid (12%). Survival of men with erythroderma was significantly lower than that of the general population.

CONCLUSION

Men with erythroderma, from causes other than Sézary syndrome, mycosis fungoides, or leukemia cutis, have a lower survival than men in the general population.

Infectious complications of erythrodermic psoriasis

Severe morbidity and mortality may be associated with erythrodermic psoriasis, especially when complicated by septicemia. We describe five patients with erythrodermic psoriasis complicated by staphylococcal septicemia. In two, concurrent infection with HIV increased vulnerability to bacteremia.

The specificity of histopathology in erythroderma

Conflicting views about the diagnostic value of skin biopsy in the investigation of erythrodermic patients are extant. The objective of the present study was to establish the frequency with which a correct diagnosis can be based on histopathological assessment alone. This was achieved by comparison of the "blinded" microscopic diagnosis with the final diagnosis (based on combined clinico-pathologic parameters and response to therapy). In a retrospective review of 56 skin biopsies from 40 patients with erythroderma, we found a positive correlation between the pathological diagnosis and the final diagnosis in 66%; furthermore, when the microscopic characteristics observed in different diagnostic categories were assessed, these proved to simulate those seen in conventional manifestations of the various underlying diseases but tended to be subtle in the setting of erythroderma. We conclude that, despite the homogeneity of the clinical expression of erythroderma, diagnostic histopathological features of the underlying disease are retained in the majority of cases.

Cutaneous markers of internal malignancy. II. Paraneoplastic dermatoses and environmental carcinogens

A variety of cutaneous disorders may reflect the presence of an internal disease. The ability to recognize those that may indicate an underlying malignancy is of particular importance. In part I of this series malignant involvement of the skin, either direct or metastatic, and the genodermatoses with malignant potential were reviewed. In this portion, we describe the paraneoplastic dermatoses as well as the cutaneous effects of some environmental carcinogens associated with internal malignancy. In addition, several uncommon and controversial associations between benign dermatoses and internal malignant disease will be discussed.

The red man syndrome. Exfoliative dermatitis of unknown etiology: a description and follow-up of 38 patients

Thirty-eight patients with erythroderma of unknown etiology were diagnosed over a 15-year period, and represented 19% of all patients admitted to our department for erythroderma. The male:female ratio was 6.6:1, and the median disease duration was 2 years (range 1 to 23 years). Keratoderma of palms and/or soles was seen in 79%. Laboratory findings were normal, except for an increased IgE level in 69% of the patients studied. Lymph node histology showed dermatopathic lymphadenopathy. Bone marrow investigation results were normal in 48%, or showed eosinophilia (32%) or hyperplasia (20%). Initial skin biopsies showed nonspecific histology in most patients, but later biopsies revealed pleomorphic infiltration. During the observation period four patients progressed to mycosis fungoides and another nine patients were suspected of having mycosis. None developed Sézary's syndrome. Only one third of the patients went into complete remission; half of them died during the observation period. Patients with erythroderma of unknown etiology are predominantly men and seem to belong to a certain subgroup--herein called the red man syndrome.