Chapter 054. Skin Manifestations of Internal Disease (Part 2)

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Erythroderma (Table 54-2) Erythroderma is the term used when the majority of the skin surface is erythematous (red in color). There may be associated scale, erosions, or pustules as well as shedding of the hair and nails. Potential systemic manifestations include fever, chills, hypothermia, reactive lymphadenopathy, peripheral edema, hypoalbuminemia, and high-output cardiac failure. The major etiologies of erythroderma are (1) cutaneous diseases such as psoriasis and dermatitis (Table 54-3); (2) drugs; (3) systemic diseases, most commonly CTCL; and (4) idiopathic. In the first three groups, the location and description of the initial lesions, prior to the development of the...

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Chapter 054. Skin Manifestations of Internal Disease (Part 2) Erythroderma (Table 54-2) Erythroderma is the term used when the majority of the skin surface is erythematous (red in color). There may be associated scale, erosions, or pustules as well as shedding of the hair and nails. Potential systemic manifestations include fever, chills, hypothermia, reactive lymphadenopathy, peripheral edema, hypoalbuminemia, and high-output cardiac failure. The major etiologies of erythroderma are (1) cutaneous diseases such as psoriasis and dermatitis (Table 54-3); (2) drugs; (3) systemic diseases, most commonly CTCL; and (4) idiopathic. In the first three groups, the location and description of the initial lesions, prior to the development of the erythroderma, aid in the diagnosis. For example, a history of red scaly plaques on the elbows and knees would point
to psoriasis. It is also important to examine the skin carefully for a migration of the erythema and associated secondary changes such as pustules or erosions. Migratory waves of erythema studded with superficial pustules are seen in pustular psoriasis. Table 54-2 Causes of Erythroderma 1. Primary cutaneous disorders a. Psoriasisa b. Dermatitis [atopic, contact >> seborrheic or stasis (with autosensitization)]a c. Pityriasis rubra pilaris 2. Drugs
3. Systemic diseases a. Cutaneous T cell lymphoma b. Lymphoma 4. Idiopathic a Discussed in detail in Chap. 53. Table 54-3 Erythroderma (Primary Cutaneous Disorders) Initial Locati Othe Diag Treat Lesions on of Initial r Findings nostic Aids ment Lesions Psori Pink- Elbow Nail Skin Topic asisa red, silvery s, knees, dystrophy, biopsy al scale, sharply scalp, arthritis, glucocortico demarcated presacral area pustules ids, vitamin D; UV-B
(narrowband ); oral retinoid and/or PUVA; MTX, cyclosporine , anti-TNF agents Derm atitisa Atop Acute: Antec Prurit Skin Topic ic ubital and us biopsy al Erythe popliteal glucocortico ma, fine scale, Fami fossae, neck, ids, crust, indistinct ly history of hands tacrolimus, borders atopy, pimecrolimu including s, tar, and
Chronic: asthma, antipruritics; allergic oral Lichenif rhinitis or antihistamin ication conjunctiviti es; open wet (increased skin s, and atopic dressings; markings) dermatitis UV-B ± UV-A; Excl PUVA; ude oral/IM secondary glucocortico infection ids; MTX; with S. cyclosporine aureus Topic Excl al or oral ude antibiotics superimpose d irritant or allergic contact dermatitis
Cont Local: Depen Irrita Patch Remo act ds on nt—onset testing ve irritant or Erythe offending often within allergen; ma, crusting, agent hours topical vesicles, and glucocortico bullae Aller ids; oral gic— antihistamin delayed- es; oral/IM type glucocortico hypersensiti ids vity; lag time of 48 h Systemic Gener Patie Patch Same : alized nt has testing as local history of Erythe allergic ma, fine scale, contact crust dermatitis to topical agent and
then receives systemic medication that is structurally related, e.g., ethylenedia mine (topical), aminophylli ne (IV) Sebo Pink- Scalp, Flare Skin Topic rrheic (rare) red, greasy nasolabial s with biopsy al scale folds, stress, HIV glucocortico eyebrows, infection ids and intertriginous imidazoles Asso zones ciated with Parkinson's
disease Stasis Erythem Lower Prurit Skin Topic (with a, crusting, extremities us, lower biopsy al autosensitiza excoriations extremity glucocortico tion) edema ids; open wet Histo dressings; ry of venous leg ulcers, elevation; thrombophl pressure ebitis, stockings and/or cellulitis Excl ude cellulitis Excl ude superimpose d contact
dermatitis, e.g., topical neomycin Pityri Orange- Gener Wax- Skin Isotre asis rubra red, alized, but like biopsy tinoin or pilaris perifollicular characteristic keratoderma acitretin; papules "skip" areas methotrexate Excl of normal ude skin cutaneous T cell lymphoma a Discussed in detail in Chap. 53. Note: PUVA, psoralens + ultraviolet A irradiation; UV-B, ultraviolet B; UV-A, ultraviolet A; MTX, methotrexate; TNF, tumor necrosis factor.