Exfoliative dermatitis

M . IZAZI HP
Departemen Ilmu Kesehatan Kulit dan Kelamin Fakultas Kedokteran UNSRI/RSMH Palembang 2011
dr. M. Izazi HP SpKK 1

2009

4/8/2013

Exfoliative dermatitis (ED) or Erythroderma

characterized diffuse erythema & scaling involving >90% total body skin surface Cause ED unknown, approximately 20% cases idiopathic ED

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dr. M. Izazi HP SpKK

Exfoliative dermatitis (ED)

Common underlying etiologies psoriasis, atopic dermatitis, spongiotic dermatoses,drug hypersensitivity reaction, cutaneous T cell lymphoma(CTCL) Systemic complications fluid & electrolyte imbalance, thermoregulatory disturbance, fever, tachycardi, High-output failure, hypoalbuminemia, peripheral edema

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dr. M. Izazi HP SpKK

Epidemiology

Incidence 0,9-71,0/100000 outpatient Male > female ratio 2,1 : 4,1 Average onset 41 61, rare children Many diseases associated ED exacerbation previously localized disease >1/2 psoriasis identified almost cases

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dr. M. Izazi HP SpKK

Etiology
Drug Calcium channel blocker Anti-epileptic antibiotics (penicillin family, sulfonamides vancomycin Allopurinol,gold,lithium Quinidine Cimetidine Dapsone

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dr. M. Izazi HP SpKK

ED atopic dermatitis
ED atopic dermatitis, psoriasis and CTCL Circulating intercellular adhesion molecule 1 (ICAM 1) Vascular cell adhesion molecule1 (VCAM1) E-selectin

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dr. M. Izazi HP SpKK

Possible trigger ED psoriasis

Discontinuation poten topical or oral CS, metotraxate, or biologic treatment (efalizumab) Medicationlithium,terbinafine,antimalaria Topical irritanTar Infection HIV infections Pregnancy Emotional stress Systemic illness
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Chronic Idiopathic ED

risk progression mycosis fungoides or sezary syndrome Theorieschronic T-cell stimulation in chronic ED (atopic ED)promote developed CTCL In elderly patients with chronic or relapsing ED monoclonal CD4+CD7CD26- lymphocytes monoclonal Tcell dyscrasia of undertermined significance
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Pathogenesis

Not well understood Theorized staphylococcus aereus colonization (83% in the nares& 17% skin &nares) or another antigen (shock syndrome toxin-1) Cytokine profileTh1 cytokine Different profilebenign ED mechanism Sezary syndrome Th2cytokine IgE
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ED in psoriasis

Universal erythem, thickening skin, heavy scaling

Patient had fatigue,malaise, shivering

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BLEPHARITIS ED atopic dermatitis

Chronicity,edema,lichenification skin induration

Ectropion & epiphora secondary to chronic periorbital involvement

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ED in pityriasis rubra pilaris

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SEZARY SYNDROME

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Related physical finding

Thermoregulator disturbance hyperthermia/ hypothermia most patients complain of feeling chilly Tachycardiaincreased blood flow to the skin High-output cardiac failure Peripheral pedal or pretibial edema Generalized lymphadenopathy Hepatomegaly Splenomegaly

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Laboratoric finding
Non specific Anemia, leucocytosis, lymphocitosis eosinophilia, IgE, ERS abnormal Electrolyte & creatinine Sezary syndrome circulating cell sezary >20% Quantitative real-time PCR assay molecular diagnosis Sezary syndrome Predominance CD4+
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Complication

Systemic fluid & electrolyte imbalance Thermoregulatory disturbance Fever Hypoalbunemia Peripheral edema susceptibility bacterial colonization Sepsis CTCL & HIV (+) risk staphylococcus sepsis

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Treatment

fluid & electrolyte Replacement ED caused drug discontinous Enviroment warm & humid Preventing hypothermia Gentle local skin care Bland emollient

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Treatment

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Topical treatment
Started CS low potency CS high potency, immunomodulator (tacrolimus) avoided Systemic Topical irritants absorption (anthralin&tar) avoided

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Treatment systemic

Psoriasis EDSystemic CS avoided Psoriasis ED reponsive MTX, cyclosporine,acitretin, mycophenolate mofetil, th/ biologic

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Treatment symptomatic
Sedating antihistaminpruritus Diuretica & leg elevation leg edema refractory Systemic antibiotic
localized & systemic secondary infection Without evidence secondary infection as bacterial colonization

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Approach ED

CBC=complete blood cell

CXR=chest X-ray
PCP=primary care physician
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