Erythrodermic psoriasis is a generalized inflammatory form of psoriasis. The complications of psoriatic exfoliative erythroderma is due to the protein and fluid loss through the excessive and continuous shedding of scales from the skin surface.
What is the Cause for Erythrodermic Psoriasis?
Erythrodermic psoriasis is a complication seen in 16-24% of cases of psoriasis. It generally appears in people who have unstable type of plaque psoriasis, where the disease is progressively worsening.
Erythrodermic psoriasis is usually precipitated by the sudden withdrawal of systemic corticosteroids or potent topical steroids, therapy with chloroquin or beta adrenergic receptor blockers, or by over treatment with tar or dithranol.
Is Psoriasis the Only Cause of Exfoliative Erythroderma?
No, exfoliative erythroderma can occur as a complication of atopic dermatitis, drug reactions, lymphoma, contact allergic dermatitis, pityriasis rubra pilaris. In 50% of cases, no cause is found, hence called idiopathic exfoliative erythroderma.
What the Signs and Symptoms of Erythrodermic Psoriasis?
- Erythrodermic psoriasis is characterized by widespread redness, scaling and thickening of the skin. The scales in psoriasis erythroderma are not as thick as in the plaque psoriasis. The scales are greasy.
- The erythema (reddening) and exfoliation (shedding) of the skin are often accompanied by severe itching and pain. The skin color is a dusky red in psoriatic erythroderma.
- Edema due to the fluid retention causes swelling around the ankles. Disruption of the body’s temperature regulation leads to shivering episodes.
- Benign enlargement of lymph nodes known as lipomelanotic reticulosis is common in erythrodermic psoriasis. This is caused by the absorption of impurities and inflammatory products from the peeling skin.
- Depending upon the duration of the disease, exfoliative erythroderma can be acute, sub acute or chronic varieties.
What are the Complications of Erythrodermic Psoriasis?
- Daily loss of large quantities of epidermal scales rich in proteins, iron, vitamin B12 and folic acid cause anemia, hypocalcemia and hypoalbuminemia in patients.
- Coupled with the above, generalized body fluid loss completely throws off body chemistry causing other complications caused by fluid and electrolyte imbalance. Hence severe erythrodermic psoriasis has to be treated as a skin emergency.
- Severe skin irritation triggers associated disturbances in the gastro-intestinal system causing malabsorption of food. Nutritional and protein deficiency is common in this type of psoriasis.
- The barrier function of the skin is impaired in erythrodermic psoriasis leading to increased absorption of topical applications. This may lead to increased systemic toxicity to topical medications. Due to decreased renal blood flow, oliguria (reduced urine production and excretion) can occur. The blood flow in the skin is increased and cardiac output (blood flow from the heart) is raised. This may result in high output cardiac failure.
- Secondary bacterial infection, pneumonia and congestive heart failure caused by psoriatic exfoliative erythroderma can be life threatening. People with severe cases of this condition are often hospitalized and treated by a combined team consisting of a dermatologist, physician, cardiologist and nephrologists.
How is Erythrodermic Psoriasis Treated?
Following are the principles of treatment of erythrodermic psoriasis:
- General measures: Patient is hospitalized, admitted in a single room. The temperature and humidity should be controlled according to the patient’s comfort levels.
- Topical therapy for psoriatic erythroderma: Oil baths followed by bland emollients. Topical steroids are avoided.
- Systemic treatment: Antibiotics for secondary infection, and oral steroids for control of the disease progression. Steroid sparing immune suppressing therapy with methotrexate, cyclosporine, azothioprine etc are also useful. Oral retinoids are effective in some patients. The biological therapy has given a new hope for erythrodermic patients.
- Supportive treatment to take care of the cardiac, renal, fluid, electrolyte, protein replacement therapy etc is required for the patients.
Reference: Psoriasis, in Rook’s Textbook of Dermatology, 7th Edition, 2004
Disclaimer
The information given in this article is for educational purpose only so that patients are aware of the options available. No diagnosis should be made or treatment undertaken without first consulting your doctor. If you do so, the author or suite101 will not be responsible for any consequences. The images provided are for illustration purpose only.
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