Erythroderma: analysis of 247 cases

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

Erythroderma, often described as generalized exfoliative dermatitis, is a condition in which erythema involves greater than 90% of the body surface, often as a result of an underlying inflammatory skin condition, which can result in a variety of systemic manifestations and potentially lead to life-threatening complications.

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.

A Study of Correlation Between Clinical and Histopathological Findings of Erythroderma in North Bengal Population

Background:

Erythroderma is a reaction pattern characterized by erythema and desquamation of 90% or more body surface area along with some metabolic alterations.

Materials and Methods:

Here we studied 32 patients of erythroderma at of North Bengal Medical College for a period of 1 year to find the etiology, clinical features and histological changes. Detailed history was taken from all the patients followed by relevant biochemical investigations and histological examination. To correlate the clinical and histopathological findings chi square test was used.

Results:

Male preponderance was present and most of them were in the 4^th or 5^th decade. Etiologically the patients were divided into secondary erythroderma developing over pre-existing dermatoses, and idiopathic erythroderma. Secondary erythroderma (n = 24) cases outnumbered the idiopathic cases (n = 8). Among the pre-existing dermatoses, psoriasis was found to be the most common etiologic agent. Apart from erythema the other common presenting features were scaling and itching. Histopathological categorization was possible in 59.3% cases, rest of the cases showed non-specific dermatitis. The most common histopathologic diagnosis was psoriasis (21.8% of cases).

Conclusions:

Our study of clinicopathological correlation of erythroderma patients among north bengal population corroborates with most of the previous studies done in other areas. As ours is a cross-sectional study in a undefined population so we could not determine the true incidence of erythroderma in north bengal population. We might have missed lymphoma as a cause of erythroderma in idiopathic cases due to lack of long follow-up, so we understand that further studies over a defined population with long follow-up is needed to determine the true incidence and causes of idiopathic erythroderma.

Epidemiology and treatment of psoriasis: a Brazilian perspective

Psoriasis is a chronic immune-mediated systemic disease that is influenced by genetic and environmental factors, is associated with comorbidities, and has a negative impact on the quality of life of affected individuals. The prevalence of psoriasis varies among different ethnic groups, but this topic has not been studied in Brazil to date. In this review, we evaluate the epidemiology and treatment of psoriasis from a Brazilian perspective. We focused on studies that involved Brazilian subjects. The prevalence of psoriasis in Brazil is estimated to be 2.5%, but no population study has been performed previously. Environmental factors, such as tropical climate, in association with genetic factors, such as miscegenation, may exert a beneficial impact on the course and frequency of psoriasis in Brazil. A number of studies have advanced our understanding of the cardiovascular, ophthalmic, and oral comorbidities that are associated with psoriasis. Concerns about biological therapy, such as endemic leprosy, human T-cell lymphotropic virus (HTLV), and tuberculosis infections, are discussed. The nonavailability of treatment options for psoriasis in the public health system contradicts the Brazilian Society of Dermatology guidelines, stimulating the judicialization of access to medicines in psoriasis care.

Clinico-etiological study of 30 erythroderma cases from tertiary center in South India

Background:

Erythroderma is a morphological reaction pattern of skin having many underlying causes and finding the etiology helps in the proper management of erythroderma cases.

Aim:

To evaluate the clinical profile, etiology of erythroderma and to correlate clinical diagnosis with histopathology.

Materials and Methods:

This study was performed at the department of dermatology, Father Muller Medical College and Hospital, Mangalore, South India. We studied 30 consecutive cases of erythroderma with respect to the epidemiological, clinical and histological data. Clinico-histological correlation was analyzed for etiology of erythroderma.

Results:

The mean age of onset was 52.3 years with a male to female ratio of 14:1. In addition to erythroderma, other co-existent features included pruritus, fever, lymphadenopathy, and edema. Of the pre-existing dermatoses, psoriasis was the most common (33.3%) disease followed by eczema (20%), atopic dermatitis (6.6%), pityriasis rubra pilaris (3.3%) and drug-induced erythroderma (16.6%). In 16.6% of cases, etiology could not be ascertained. Clinico-histopathological correlation could be established in 73.3% of cases.

Conclusion:

Clinical features were identical irrespective of etiology. Detailed clinico-histopathological examination helps to establish the etiology of erythroderma.

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.

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).

Keratosis lichenoides chronica: report of a case developing after erythroderma

A 66-year-old male presented with keratosis lichenoides chronica after a presumed drug-induced erythroderma. After resolution of the erythroderma, slightly scaly erythematous and violaceous papules in a reticular arrangement over the trunk and limbs developed in association with hoarseness, palmoplantar keratoderma, onycholysis and subungual keratosis. Histology from a lichenoid lesion showed pseudo-epitheliomatous hyperplasia, hyperorthokeratosis, parakeratosis, dyskeratosis, neutrophil exocytosis and focal vacuolar degeneration of the basal layer of the epidermis. There was a band-like chronic inflammatory infiltrate in the upper dermis. The skin improved with prednisone 40 mg/day for 15 days, leaving atrophic hypopigmented scars. A diagnosis of keratosis lichenoides chronica was made.

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.