Skin care Exfoliative or Exudative Erythroderma

What's the difference between exfoliative erythroderma and exudative erythroderma and how can a patient/caregiver best treat/deal with each?

Answer:

Erythroderma means 80-100% of the total skin surface has a generalized redness or erythema with variable degrees of scaling.  Many patients complain of fever, chills, shivering, and malaise.  There are multiple causes including drugs, chronic skin diseases such as psoriasis, atopic dermatitis, contact dermatitis, cutaneous T-cell lymphoma and other lymphoreticular malignancies.

Exfoliative erythroderma refers to erythroderma with severe scaling and extreme loss of skin and “shedding like snow.”  Exudative erythroderma means generalized redness of the skin with swelling or edema and oozing of fluid.  It can be indicative of secondary skin infection due to the interruption of the normal skin barrier.  

Erythroderma can be both exfoliative (scaling) and exudative (moist with fluid from the tissue).

How can a patient/caregiver best treat/deal with each condition?

Patients with acute onset often require hospitalization for frequent monitoring of fluids and electrolyte balance, heart failure, and nutritional needs.

If the condition is more chronic  some suggestions for home care:

  • Frequent lubrication of skin with bland emollients such as Vaseline, Aquaphor, Vaniply (all over the counter).
  • For more exudative erythroderma, apply wet dressings or clothing.  Change every 2 hours.  May use cotton pajamas with long sleeves and pants and saturate with tap water and place in dryer for 5-10 minutes to warm up.
  • To help reduce infections, take a bleach bath every 2-3 days.  Put ½ cup of household bleach in a full tub of water and soak for 10 minutes.  Do not submerge head and avoid eye contact.  Rinse off with tap water and then apply  lubrication.
  • Avoid sun exposure and when going outside cover up and wear sunglasses
  • For areas of intense itching apply intermittent ice packs or use balloons inflated with water and add a teaspoon of rubbing alcohol and put in freezer.  The balloons are quite malleable and can be reused.
  • Raise the room temperature by 3-5 degrees to avoid chills. Individuals with erythroderma lose his/her ability to maintain body heat.

Answer provided by:
Elizabeth McBurney, MD, FACP
Clinical Professor of Dermatology
Tulane School of Medicine
Louisiana State University School of Medicine 
New Orleans, Louisiana
Private practice, Sanova Dermatology, Lafayette, LA

Answer:

Erythroderma is the term used to describe generalized skin redness. It can present with thickening of palms and soles, damage to the fingertips, breakage of nails, dry eyes, and even swelling of legs. In some diseases, such as Sézary syndrome (SS), erythroderma can be the first symptom. For other already diagnosed skin conditions, such as eczema, psoriasis or mycosis fungoides (MF), a flare of the disease can show up as erythroderma. 

In addition to redness, erythroderma can be accompanied by weeping lesions (exudative erythroderma) or dry scales (exfoliative erythroderma). These presentations may suggest underlying diseases. For example, exudative erythroderma is commonly seen in blistering diseases and exfoliative erythroderma in psoriasiform diseases. These two subtypes can coexist in MF/SS. 

The initial management of erythroderma is the same regardless of etiology: 

  • Baths with lukewarm water and wet dressings to weeping or crusted sites should be followed by application of bland emollients and low-potency topical corticosteroids. Higher potency topical corticosteroids are not recommended because of risk for systemic absorption secondary to the extensive body surface area and the enhanced cutaneous permeability. Skin irritants such as hydroxy acid moisturizers and tar should be avoided.
  • Fissures on fingertips are usually painful and may affect your daily activities. Apply a topical corticosteroid and cover them with a thick moisturizer.  Finger topper bandages are an option. A topical liquid skin adhesive that holds wound edges together might be prescribed by your doctor.
  • Dressing changes can be painful and cause anxiety. Speak to your doctor to evaluate the pain. You might be a candidate for pain medications to decrease the discomfort during bandage changes.
  • A thick moisturizer such as fragrance-free petroleum jelly applied on nails overnight may help prevent breakage.
  • Eye dryness can improve with artificial tears. If it is constant,  it needs to be evaluated by your ophthalmologist.
  • Swelling of distal legs is a common complication of erythroderma. It could respond to leg elevation and local skin care. 
  • Secondary superficial skin infections are common in erythroderma. They may present with small areas of malodorous weeping or yellow-crusted lesions and can be treated with topical antibiotics, such as mupirocin.  
  • Many MF/SS patients experience a clinical course characterized by waxing and waning of erythroderma, with flares occurring when the skin is heavily colonized with bacteria. These patients usually require hospitalization and therapy with wet wraps and intravenous antibiotics. 
  • Bleach baths decrease the number of bacteria in the skin, preventing superficial skin infections and flares. Use one half cup of regular strength bleach to a full tub of water two to three times a week. If baths are not an option, you could shower with an antibacterial wash that contains chlorhexidine gluconate.
  • Speak to your physician about erythroderma. Severe erythroderma may require hospitalization for systemic complications (infection, fluid and electrolyte imbalances, thermoregulatory disturbance, cardiovascular and respiratory compromise).
     

Answer provided by:
Lucia Seminario-Vidal, MD, PhD
Assistant Professor 
Department of Dermatology and Cutaneous Surgery
University of South Florida; and
Co-Director 
Cutaneous Lymphoma Multidisciplinary Clinic 
Moffitt Cancer Center

References:

  • Mangold AR, Thompson AK, Davis MD, Saulite I, Cozzio A, Guenova E, Hodak E, Amitay-Laish I, Pujol RM, Pittelkow MR, Gniadecki R. Early clinical manifestations of Sézary syndrome: A multicenter retrospective cohort study. J Am Acad Dermatol. 2017 Oct;77(4):719-727.
  • Rym BM, Mourad M, Bechir Z Dalenda E, Faika C, Iadh AM, et al. Erythroderma in adults: A report of 80 cases. Int J Dermatol. 2005;44:731–5.
  • Rothe MJ, Bialy TL, Grant-Kels JM. Erythroderma. Dermatol Clin. 2000; 18:405–15.
  • Rothe MJ, Bernstein ML, Grant-Kels JM. Life-threatening erythroderma: Diagnosing and treating the “red man” Clin Dermatol. 2005;23:206–17.
  • Talpur R, Bassett R, Duvic M. Prevalence and treatment of Staphylococcus aureus colonization in patients with mycosis fungoides and Sezary syndrome. Br J Dermatol 2008;159:105–112.
  • Lewis DJ, Holder BB, Duvic M. The “Duvic regimen” for erythrodermic flares secondary to Staphylococcus aureus in mycosis fungoides and Sézary syndrome. Int J Dermatol. 2018 Jan;57(1):123-124.