Erythroderma

Utility of Dermoscopy in the Diagnosis of Erythroderma: A Cross-Sectional Study

Background

It is difficult to diagnose the underlying cause of erythroderma on mere clinical presentation. The role of dermoscopy in diagnosing erythroderma secondary to various etiologies is evolving.

Aim and Objectives

This study aimed to observe the dermoscopic features of erythroderma secondary to different cutaneous disorders and compare them with clinical features and histopathology.

Materials and Methods

Twenty-nine consecutive patients of erythroderma were enrolled in the study. Dermoscopy was performed on every case using a Heine Delta II Dermatoscope with 10x magnification in polarized mode. A histopathological examination was conducted to confirm the diagnosis.

Results

Eight patients were diagnosed with psoriasis, five with endogenous eczema, four with pityriasis rubra pilaris (PRP), three with pustular psoriasis, two with drug rash secondary to antitubercular therapy, two with dermatophytic infection, one patient each of atopic dermatitis, crusted scabies, pemphigus foliaceous, drug reaction with eosinophilia and systemic symptoms, and mycosis fungoides. Characteristic dermoscopic features were observed in erythroderma due to psoriasis, PRP, pustular psoriasis, endogenous eczema, scabies, and dermatophytosis. Differentiation of other disorders based on dermoscopy alone was difficult, and clinico-histopathological correlation was crucial to reach a diagnosis.

Conclusion

Dermoscopic features of classical patterns of skin disorders are preserved even in the corresponding erythrodermic or unstable stage. Dermoscopic features of erythroderma secondary to psoriasis, pustular psoriasis, PRP, endogenous eczema, scabies, and dermatophytosis are clearly differentiating, whereas the dermoscopic features in other causes of erythroderma are overlapping. Thus, dermoscopy can be a good screening tool in the clinical assessment of erythroderma.

Acute Exfoliative Dermatitis/Erythroderma Secondary to Gliclazide

Erythroderma is a general term used to describe severe, intense skin inflammation. The condition is also known as exfoliative dermatitis when it is associated with exfoliation. Erythroderma has many causes, such as adverse drug eruption, dermatitis, psoriasis, pityriasis rubra pilaris, immunobullous disease, cutaneous T-cell lymphoma (Sézary syndrome), underlying systemic malignancy, graft versus host disease, and HIV infection. Many medications can cause erythroderma, including antibiotics, antiepileptics, angiotensin-converting enzyme (ACE) inhibitors, and sulfonamides. Here, we report a rare case of erythroderma secondary to gliclazide, an oral antidiabetic. This presentation is rare, as we found only one case report of gliclazide causing erythroderma in the literature. Erythroderma is considered a medical emergency requiring immediate diagnosis and prompt management; therefore, early intervention should start on suspicion without waiting for dermatologist confirmation, as this will significantly reduce the mortality and morbidity of this potentially life-threatening emergency.

A nomogram diagnostic cardiovascular disease in patients with erythrodermic psoriasis in Chinese

Objective

Patients with erythrodermic psoriasis (EP) are associated with an increased risk of cardiovascular disease (CVD), because of the more severe inflammation in the skin areas. This study aimed to develop a diagnostic model for the risk of CVD in EP patients based on the available features and multidimensional clinical data.

Methods

A total of 298 EP patients from Beijing Hospital of Traditional Chinese Medicine were retrospectively included in this study from May 5^th, 2008, to March 3^rd, 2022. Of them, 213 patients were selected as the development set by random sampling, and clinical parameters were analyzed by univariate and backward stepwise regression. Whereas the remaining 85 patients were randomly selected as the validation set. The model performance was later assessed in terms of discrimination, calibration, and clinical usefulness.

Results

In the development set, the CVD rate was 9%, which was independently correlated with age, glycated albumin (GA>17%), smoking, albumin (ALB<40 g/L), and lipoprotein(a) (Lp(a)>300 mg/L). The area under the ROC curve (AUC) value was 0.83 (95% confidence interval CI, 0.73,0.93). For the validation set of EP patients, the AUC value was 0.85 (95%CI, 0.76,0.94). According to decision curve analysis, our model exhibited favorable clinical applicability.

Conclusion

EP patients with age, GA>17%, smoking, ALB<40 g/L, and Lp(a)>300 mg/L are associated with a higher risk of CVD. The nomogram model performs well in predicting the probability of CVD in EP patients, which may help improve perioperative strategies and good treatment outcomes.

Toxic Shock Syndrome Secondary to Erythroderma: Unraveling the Underlying Triggers

Toxic shock syndrome (TSS) is a rare and life-threatening condition characterized by the systemic manifestation of severe infection. It is caused by exotoxin-producing strains of Staphylococcus aureus and Streptococcus pyogenes. Erythroderma, often described as generalized exfoliative dermatitis, is a rare and severe dermatological condition involving more than 90% of the body surface, identified as an uncommon cause of TSS. Here, we describe a case of a 72-year-old male who presented with signs and symptoms of erythroderma presenting as extensive erythematous scaling and lichenified plaques on multiple body surfaces and later developed TSS.

Efficacy and Safety of Dupilumab in Patients With Erythrodermic Atopic Dermatitis: A Post Hoc Analysis of 6 Randomized Clinical Trials

Importance

Erythrodermic atopic dermatitis (AD) is a severe AD subtype defined by extensive skin involvement, leading to complications and sometimes hospitalization.

Objective

To assess dupilumab's efficacy and safety in patients with erythrodermic AD in clinical trials.

Design, Setting, and Participants

This post hoc analysis included patients enrolled in 6 multicenter, multinational, randomized, double-blind, placebo-controlled trials. Patients included in this analysis met erythrodermic AD criteria of 90% or greater body surface area (BSA) affected by AD and Global Individual Sign Score for erythema of 1 or higher. Data analyses for this post hoc analysis were conducted between March 5, 2019, and October 24, 2020.

Interventions

Dupilumab once weekly or every 2 weeks, or placebo, either as monotherapy or with concomitant topical corticosteroids (TCS).

Main Outcomes and Measures

Efficacy (BSA, Eczema Area and Severity Index [EASI] score, Peak Pruritus Numerical Rating Scale [PP-NRS] score), changes in serum biomarkers (thymus and activation-regulated chemokine, total immunoglobulin E, lactate dehydrogenase), and safety (incidence of adverse events) at week 16. Data were pooled within each regimen; monotherapy and concomitant TCS results are shown separately.

Results

Of 3075 randomized patients, 209 met criteria for erythrodermic AD at baseline, with the median age being 31 and 39 years in the monotherapy and concomitant TCS trials, respectively, similar to the overall populations (34 and 36 years, respectively); 71.3% (n = 97) and 74.0% (n = 54) of patients, respectively, were male (compared with 58.7% and 60.6% in the overall populations). In patients with erythrodermic AD, dupilumab once weekly and every 2 weeks vs placebo significantly improved percentage of BSA affected by AD (least squares mean percent change [SE]) with monotherapy (-42.0% [7.7%] and -39.9% [6.5%] vs -17.2% [11.0%]; P = .03) and concomitant TCS (-63.2% [6.7%] and -56.1% [9.1%] vs -14.5% [7.3%]; P < .001); EASI score with monotherapy (-58.5% [9.0%] and -58.3% [7.9%] vs -22.3% [12.4%]; P = .004 and P = .003, respectively) and concomitant TCS (-78.9% [7.8%] and -70.6% [10.1%] vs 19.3% [8.2%]; P < .001); and PP-NRS score in monotherapy (-45.9% [7.8%] and -33.9% [6.6%] vs -0.6% [9.4%]; P < .001) and concomitant therapy (-53.0% [8.1%] and -55.7% [10.8%] vs -26.0% [8.8%]; P = .006 and P = .01, respectively). Nominally statistically significant improvement was seen as early as week 1 (EASI and PP-NRS scores with monotherapy). Biomarker levels were significantly reduced vs placebo. The most frequent adverse events in dupilumab-treated patients were injection-site reaction, conjunctivitis, and nasopharyngitis.

Conclusions and Relevance

In this post hoc analysis of 6 randomized clinical trials, treatment with dupilumab resulted in rapid, sustained improvements in AD signs and symptoms with acceptable safety in patients with erythrodermic AD, similar to those in the trials' overall patient population.

Trial Registration

ClinicalTrials.gov Identifiers: NCT01859988, NCT02277743, NCT02277769, NCT03054428, NCT02260986, NCT02755649.

Erythroderma (exfoliative dermatitis). Part 1: underlying causes, clinical presentation and pathogenesis

Erythroderma (exfoliative dermatitis), first described by Von Hebra in 1868, manifests as a cutaneous inflammatory state, with associated skin barrier and metabolic dysfunctions. The annual incidence of erythroderma is estimated to be 1-2 per 100 000 population in Europe with a male preponderance. Erythroderma may present at birth, or may develop acutely or insidiously (due to progression of an underlying primary pathology, including malignancy). Although there is a broad range of diseases that associate with erythroderma, the vast majority of cases result from pre-existing and chronic dermatoses. In the first part of this two-part concise review, we explore the underlying causes, clinical presentation, pathogenesis and investigation of erythroderma, and suggest potential treatment targets for erythroderma with unknown causes.