Erythroderma: Causes, Symptoms, Management, Complication by Nurses Note

 Erythroderma

Erythroderma is the term used to describe diffuse widespread erythema of the skin, involving more than 90% of the body surface area. It can be the manifestation of many cutaneous and systemic diseases.

Erythroderma must be treated aggressively, as the consequences of widespread changes to the skin can result in infection, fluid and electrolyte imbalance, thermodysregulation, high-output cardiac failure, and acute respiratory distress. Establishing the underlying cause is difficult, and erythroderma is often classified as idiopathic.

Epidemiology of Erythroderma

The average reported age range is 41 to 61 years where most published studies have excluded children. The proportion of idiopathic cases ranges from 9 to 47%.

 Causes of Erythroderma

Common causes are psoriasis, eczema, and drug reactions. However, there is a wide range of possible underlying pathologies:

•  Dermatoses:

•  Psoriasis.

•  Atopic dermatitis (eczema).

•  Cutaneous T cell lymphoma.

•  Pityriasis rubra pilaris.

•  Superficial pemphigus.

•  Bullous pemphigoid.

•  Contact dermatitis.

•  Infections:

•  Fungal.

•  Norwegian scabies.

•  HIV.

•  Tuberculosis.

•  Systemic:

•  Subacute cutaneous lupus.

•  Dermatomyositis.

•  Acute graft versus host disease.

•  Post-operative transfusion-induced.

•  Sarcoidosis.

•  Thyrotoxicosis.

•  Haematological:

•  Hodgkin’s lymphoma.

•  B cell lymphoma.

•  Chronic lymphocytic leukaemia.

•  Myelodysplasia.

•  Malignancies

•  Prostate, lung, thyroid, liver, breast, ovary.

•  Drugs

•  Allopurinol, anticonvulsants, antibiotics.

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Symptoms of Erythroderma

Symptoms related to erythroderma include thermoregulatory disturbance, malaise, fatigue, and pruritus. In long standing erythroderma, lichenification, diffuse alopecia, dermatopathic lymphadenopathy, keratoderma (skin thickening), nail dystrophy, and ectropion can all be seen. Pitting pretibial and pedal oedema is found in 50% of erythrodermic patients. Other clinical features depend on the underlying aetiology.

Common laboratory abnormalities include:

•  High white cell count.

•  Lymphocytosis.

•  Anaemia.

•  Eosinophilia.

•  High ESR.

•  High serum IgE.

Other abnormalities may include:

•  Raised creatinine.

•  Raised uric acid.

•  Low serum protein.

Skin biopsy may prove helpful, and sometimes repeated biopsies over time are necessary to reach a diagnosis. HIV status should be considered.

Management of Erythroderma

•  Admit the patient.

•  Nurse in a warm, humid environment.

•  Assess the fluid and electrolyte balance.

•  Assess the patient's nutritional requirements.

•  Administer bland emollients.

•  Prescribe low-potency topical corticosteroids (note increased absorption through the skin, with large body surface area involvement in erythroderma).

•  Antihistamines may be required for pruritus.

•  Prescribe systemic antibiotics for secondary infection.

•  Discontinue all non-essential medications.

•  If peripheral oedema is persistent and does not respond to leg elevation and skin care, consider treatment with diuretics. Topical immunomodulators, tar preparations, and hydroxyl acid moisturizers are best avoided.

Further management depends on the underlying aetiology. 

Systemic corticosteroids are recommended for patients with systemic drug hypersensitivity reactions but should be avoided in patients with possible underlying psoriasis.

Complications of Erythroderma

•  Infections, including sepsis.

•  Fluid and electrolyte losses.

•  Protein loss (oedema, muscle wasting, hypoalbuminaemia, and high-output cardiac failure).

•  Thermodysregulation.

Staphylococcal sepsis is a risk for patients with cutaneous T cell lymphoma and HIV-positive erythrodermic patients.

Prognosis

The natural course of the condition is dependent on underlying aetiology