Fig. 26.1
Upper panel illustrates an old woman with “exfoliative dermatitis” involving the whole skin surface including the face. The eruption was resistant to topical and systemic steroids. Histological evaluation demonstrated crusted scabies. Lower panel illustrates an old woman with recent onset psoriasis erythroderma
Case
A patient presents with rapidly progressive eruption. Examination reveals total skin redness and scaling.
Clinical differential diagnosis includes
psoriasis
pityriasis rubra pilaris (PRP)
atopic dermatitis
Sezary syndrome (SS)
drug-induced erythroderma
crusted scabies, and rarely
pemphigus foliaceous (PF).
The discussion is limited to acquired primary skin disorders that may present with exfoliative erythroderma. Other disorders that may present with exfoliative erythroderma include some types of ichthyosis. As these are known since early childhood, they are not discussed here. Erythroderma secondary to viral or bacterial exanthem is generally without scaling and patients usually have systemic symptoms, and will not be discussed here. Also, morbilliform drug eruption that may show fine desquamation as the eruption involutes will not be discussed.
Clinical Clues
History
Patients with exfoliative erythroderma secondary to psoriasis, atopic dermatitis, crusted scabies, and pemphigus foliaceous generally have a preceding limited skin disorder for weeks to years before advancing to total skin involvement. On the other hand, exfoliative erythroderma secondary to drug-induced or Sezary syndrome is not preceded by a limited eruption but instead becomes generalized soon after the onset.
Of the three most common causes of exfoliative erythroderma (psoriasis, PRP, and atopic dermatitis), PRP erythroderma is the most likely to develop over a short period of time, generally a few weeks; while patients with exfoliative erythroderma secondary to psoriasis or atopic dermatitis generally have the disorder for several years prior to dissemination.
Predisposition to generalized crusted (Norwegian) scabies includes prolonged treatment with steroids and immunosuppression. In endemic areas (fogo selvagem) and untreated severe sporadic cases of PF , patients may present with generalized exfoliation instead of shallow erosions.
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