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

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.