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
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

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

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

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

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