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  • Exfoliative erythroderma is a serious, at times life-threatening, reaction pattern of the skin characterized by a uniform redness, infiltration, and scaling, which involves >90% of the skin.

  • It is associated with fever, malaise, shivers, and generalized lymphadenopathy.

  • In the acute phase, there is rapid onset of generalized erythema. Skin is warm to touch, and scale presents few days afterwards. In chronic EES, the skin thickens, and can feel leathery.

  • There may be loss of scalp and body hair. Nails become thickened, and may lift from the nail bed (onycholysis) or shed (onychomadesis).

  • There may be hyperpigmentation or patchy loss of pigment in skin of color.

  • The most frequent preexisting skin disorders are psoriasis, atopic dermatitis, adverse cutaneous drug reaction, lymphoma, allergic contact dermatitis, seborrheic dermatitis, and pityriasis rubra pilaris.

[See “Sézary Syndrome” in Section 21 for a special consideration of this form of exfoliative erythroderma.]


AGE OF ONSET Middle-aged adults.

SEX Males > females.


Some 50% of patients have a history of preexisting dermatosis. Most frequent are psoriasis, atopic dermatitis, adverse cutaneous drug reactions, cutaneous T-cell lymphoma (CTCL), allergic contact dermatitis, seborrheic dermatitis, and pityriasis rubra pilaris. Drugs most commonly implicated are shown in Table 8-1. In ∼30% of patients, it is not possible to identify the cause.

TABLE 8-1The Most Commonly Implicated Drugs in Exfoliative Dermatitisa


The metabolic response to exfoliative erythroderma may be profound. Large amounts of warm blood are present in the skin caused by dilatation of the capillaries, resulting in considerable heat dissipation. Also, there may be high-output cardiac failure; the loss of scales (and thus proteins) through exfoliation can be considerable, up to 9 g/m2 of body surface per day.


Depending on the etiology, the acute phase may develop rapidly, usually in a drug reaction, or psoriasis. At this early acute stage, it is still possible to identify the preexisting dermatosis. There is fever, pruritus, fatigue, weakness, anorexia, weight loss, malaise, feeling cold, and shivers.

APPEARANCE OF PATIENT Frightened, red, “toxic,” may be malodorous.

SKIN LESIONS Skin is red, thickened, and scaly. Dermatitis is uniform involving the entire body surface ...

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