Sauer’s Manual of Skin Diseases
9th Edition

19
Exfoliative Dermatitis
John C. Hall
As the term implies, exfoliative dermatitis is a generalized scaling eruption of the skin. The causes are many. This diagnosis should never be made without additional qualifying etiologic terms.
This is a rare skin condition, but many general physicians, residents, and interns see these cases because the patients are occasionally hospitalized. Hospitalization serves two purposes, namely to (1) perform a diagnostic workup, because the cause, in many cases, is difficult to ascertain and (2) administer intensive therapy under close supervision, especially in cases where the overall condition of the patient is poor. Exfoliative dermatitis can lead to sepsis, high-output congestive heart failure, and dehydration.
Classification of the cases of exfoliative dermatitis is facilitated by dividing them into primary and secondary forms.
Primary Exfoliative Dermatitis
These cases develop in apparently healthy persons from no ascertainable cause.
Presentation and Characteristics
Skin Lesions
Clinically it may be impossible to differentiate this primary form from the one in which the cause is known or suspected. Various degrees of scaling and redness are seen, ranging from fine, generalized, granular scales with mild erythema to scaling in large plaques, with marked erythema (generalized erythroderma) and lichenification. Widespread lymphadenopathy is usually present. The nails become thick and lusterless, and the hair falls out in varying degrees.
Subjective Complaint
Itching, in most cases, is intense. The patient may be toxic.
Course
The prognosis for early cure of the disease is poor. The mortality rate is high in older patients because of generalized debility and secondary infection.
Causes
Various authors have studied the relationship of lymphomas to cases of exfoliative dermatitis. Some believe the incidence to be low, but others state that from 35% to 50% of these exfoliative cases, particularly those in patients older than the age of 40 years, are the result of lymphomas. However, years may pass before the lymphoma becomes obvious.
Laboratory Findings
There are no diagnostic changes, but the patient with a usual case has an elevated white blood cell count with eosinophilia. Biopsy of the skin is not diagnostic in the primary type, but may help to rule out a more specific diagnosis. Biopsy of an enlarged lymph node, in either the primary or the secondary form, reveals lipomelanotic reticulosis (dermatopathic lymphadenopathy) which is benign.
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Treatment
Case Example
A 50-year-old man presents with a generalized, pruritic, scaly, erythematous eruption that he has had for 3 months.
First Visit
  • A general medical workup is indicated.
  • A high-protein diet should be prescribed because these patients have an increased basal metabolic rate and catabolize protein.
  • Bathing instructions are variable. Some patients prefer a daily cool bath in a colloid solution for relief of itching (one box of soluble starch or 1 cup of Aveeno to 10 inches of water). For most cases, however, generalized bathing dries the skin and intensifies the itching.
  • Provide extra blankets for the bed. These patients lose a lot of heat through their red skin and consequently feel chilly.
  • Locally, an ointment is most desired, but some patients prefer an oily liquid. Formulas for both follow:
    • White petrolatum 240.0
      or a generic corticosteroid ointment, such as triamcinolone 0.025% ointment 240.0
      Sig: Apply locally b.i.d.
    • Zinc oxide 40%
      Olive oil q.s. 240.0
      Sig: Apply locally with hands or a paintbrush b.i.d.
      Comment: Antipruritic chemicals can also be added to this.
  • Oral antihistamine, for example:
    Chlorpheniramine, 8 or 12 mg #100
    Sig: 1 tablet b.i.d. for itching. Warn patient of possible drowsiness.
Subsequent Visits
  • Systemic corticosteroids: For resistant cases, the corticosteroids have consistently provided more relief than any other single form of therapy. Any of the preparations can be used; for example:
    Prednisone, 10 mg #100
    Sig: 4 tablets every morning for 1 week, then 2 tablets every morning.
    Comment: Regulate dosage as indicated.
  • Systemic antibiotics may or may not be indicated.
Secondary Exfoliative Dermatitis
Most patients with secondary exfoliative dermatitis have had a previous skin disease that became generalized because of overtreatment or for unknown reasons. There always remain a few cases of exfoliative dermatitis in which the cause is unknown but suspected.
Presentation and Characteristics
Skin Lesions
The clinical picture of this secondary form is indistinguishable from the primary form unless some of the original dermatitis is present. As the exfoliation and eryth-roderma spread the characteristics of a primary skin disease, such as psoriasis, become harder to ascertain (Fig. 19-1).
Course
The prognosis in the secondary form is better than for the primary form, particularly if the original cause is definitely known and more specific therapy can be administered.
Causes
The more common causes of secondary exfoliative dermatitis are as follows.
  • Contact dermatitis (see Chap. 9)
  • Drug eruption (see Chap. 9)
  • Psoriasis (see Chap. 14)
  • Atopic eczema (see Chap. 9)
  • Pyoderma or other severe localized inflammation with a secondary id reaction (see Chap. 21)
  • Inflammatory fungal disease (i.e., a kerion) with id reaction (see Chap. 25)
  • Seborrheic dermatitis, especially in a newborn or an AIDS patient (see Chap. 13)
  • T-cell lymphoma, especially cutaneous T-cell lymphoma (CTCL) (see Chap. 26). A useful rule is that 50% of all patients older than age 50 years who have an exfoliative dermatitis have a lymphoma. The Sézary syndrome form of lymphoma is a rare cause of exfoliative dermatitis. It is considered the leukemic form of CTCL.
  • Internal cancer, leukemia, and other lymphomas
Treatment
The treatment of these cases consists of a combination of the treatment for the primary form of exfoliative dermatitis plus the cautious institution of stronger therapy directed toward the original causative skin condition. This therapy should be reviewed in the section devoted to the specific disease (see above).
FIGURE 19-1 ▪ Exfoliative dermatitis. (A) Only at the edge of the large plaques is there a suggestion of psoriasis as the underlying diagnosis. (B) Exfoliative dermatitis due to a Dilantin drug eruption.
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Suggested Reading
Botella-Estrada R, Sanmartin O, Oliver V, et al. Erythroderma. Arch Dermatol 1994;130:1503.
Pal S, Haroon TS. Erythroderma: A clinico-etiologic study of 90 cases. Int J Dermatol 1998;37:104.
Wilson DC, Jester JD, King LE Jr. Erythroderma and exfoliative dermatitis [review]. Clin Dermatol 1993;11:67.