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. Psoriasis a 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 Lesions Locati on of Init ial Lesions Othe r Findings Diag nostic Aids Treat ment Psori asis a Pink- red, silvery scale, sharply demarcated Elbow s, knees, scalp, presacral area Nail dystrophy, arthritis, pustules Skin biopsy Topic al glucocortico ids, vitamin D; UV- B (narrowband ); oral retinoid and/or PUVA; MTX, cyclosporine , anti- TNF agents Derm atitis a Atop ic Acute: Erythe ma, fine scale, crust, indistinct borders Antec ubital and popliteal fossae, neck, hands Prurit us Fami ly history of atopy, including Skin biopsy Topic al glucocortico ids, tacrolimus, pimecrolimu s, tar, and Chronic: Lichenif ication (increased skin markings) asthma, allergic rhinitis or conjunctiviti s, and atopic dermatitis Excl ude secondary infection with S. aureus Excl ude superimpose d irritant or allergic contact dermatitis antipruritics; oral antihistamin es; open wet dressings; UV- B ± UV-A; PUVA; oral/IM glucocortico ids; MTX; cyclosporine Topic al or oral antibiotics Cont act Local: Erythe ma, crusting, vesicles, and bullae Depen ds on offending agent Irrita nt—onset often within hours Aller gic— delayed- type hypersensiti vity; lag time of 48 h Patch testing Remo ve irritant or allergen; topical glucocortico ids; oral antihistamin es; oral/IM glucocortico ids Systemic : Erythe ma, fine scale, crust Gener alized Patie nt has history of allergic contact dermatitis to topical agent and Patch testing Same as local then receives systemic medication that is structurally related, e.g., ethylenedia mine (topical), aminophylli ne (IV) Sebo rrheic (rare) Pink- red, greasy scale Scalp, nasolabial folds, eyebrows, intertriginous zones Flare s with stress, HIV infection Asso ciated with Parkinson's Skin biopsy Topic al glucocortico ids and imidazoles disease Stasis (with autosensitiza tion) Erythem a, crusting, excoriations Lower extremities Prurit us, lower extremity edema Histo ry of venous ulcers, thrombophl ebitis, and/or cellulitis Excl ude cellulitis Excl ude superimpose d contact Skin biopsy Topic al glucocortico ids; open wet dressings; leg elevation; pressure stockings dermatitis, e.g., topical neomycin Pityri asis rubra pilaris Orange- red, perifollicular papules Gener alized, but characteristic "skip" areas of normal skin Wax- like keratoderma Excl ude cutaneous T cell lymphoma Skin biopsy Isotre tinoin or acitretin; methotrexate 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. . 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. 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). 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