John C. Hall MD
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 occasionally see these cases. Hospitalization serves two purposes, namely (1) to perform a diagnostic workup, because the cause, in many cases, is difficult to ascertain and (2) to administer intensive therapy under close supervision, especially in cases where the overall condition of the patient is poor. Exfoliative dermatitis can lead to sepsis, highoutput 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
Clinically, it may be impossible to differentiate this primary form from the one in which the cause is known or suspected.
1. From the history, ascertain where the exfoliative eruption began on the body. This information can aid in establishing the cause.
2. Look at the edge of an advancing exfoliative dermatitis for the characteristic lesions of the primary disease, if present.
3. As the exfoliative dermatitis becomes more widespread, the characteristics of the original skin disease become less obvious or may completely disappear. History, therefore, can be critical in making the correct diagnosis.
4. The underlying cause may not be apparent upon first evaluation, and biopsy may show no definite diagnosis. With time, however, the underlying cause, such as CTCL, may become evident. This is why close follow-up with repeated skin biopsy attempts is important.
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.
Itching, in most cases, is intense. The patient may be toxic and febrile.
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.
Various authors have studied the relationship of lymphomas with 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.
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.
Case Example: A 50-year-old man presents with a generalized, pruritic, scaly, erythematous eruption that he has had for 3 months.
1. A general medical workup is indicated.
2. A high-protein diet should be prescribed because these patients have an increased basal metabolic rate and catabolize protein.