Volume 5, No. 10 October,
2024
p
ISSN 2723-6927-e ISSN 2723-4339
CLINICAL IMPROVEMENT OF A PATIENT WITH EXFOLIATIVE DERMATITIS AND
COMPLICATIONS: A CASE REPORT
Nathania Christabella1*, Sugih Primas Adjie2, Nurwestu
Rusetiyanti3, Husna Raisa4, Nungki
Anggorowati5
Universitas Gadjah Mada, Sleman
Email: thaniachrist@gmail.com, sprimasadjie@gmail.com nurwestu.rusetiyanti@ugm.ac.id husnaraisa@yahoo.com nungki@ugm.ac.id
ABSTRACT
Exfoliative
dermatitis, or erythroderma, is a severe inflammatory skin syndrome
characterized by erythema and desquamation covering 90% of the body's surface.
Previous studies reported 83 cases of erythroderma at Dr. Soetomo
Hospital from 2011 to 2014. In Portugal, erythroderma incidence is 9.4 cases
per year, predominantly affecting individuals aged 41 to 61. The most common
causes of erythroderma are psoriasis and dermatitis. Case: A 55-year-old woman
presented to the emergency department of Rajawali
Citra Hospital on September 5, 2023, with complaints of abdominal pain,
vomiting, and cough, accompanied by itchy, dry skin on her face, arms, and
legs. The patient had a history of erythroderma for one year. Dermatological
examination revealed erythematous patches with scales on the left supraorbital
and nasal areas and xerosis on the upper extremities, abdomen, and lower
extremities. The patient was diagnosed with exfoliative dermatitis and showed
clinical improvement with a treatment regimen of 10 mg loratadine once daily
and topical desoximetasone ointment twice daily.
Erythroderma treatment depends on the underlying condition. Essential therapy
includes petrolatum, emollients, or low-potency topical steroids, which help
maintain skin barrier function and reduce acute inflammation. Antihistamines
can be used to alleviate itching and anxiety. A well combination
drugs therapy shows clinical improvement on erythroderma performance.
Keywords: Exfoliative Dermatitis, Erythroderma
INTRODUCTION
Generalized exfoliative dermatitis,
erythroderma, is a severe inflammatory skin syndrome characterized by
whole-body erythema and desquamation covering 90% of the body surface.
Erythroderma can be a primary condition when the cause is unknown or secondary,
arising from a specific disease.
In a retrospective study from Portugal,
the incidence of erythroderma is reported to be 9.4 cases per year. Previous
research conducted at Dr. Soetomo Hospital from 2011
to 2014 showed 83 cases of erythroderma. Erythroderma is more common in men,
with a male-to-female ratio of 2-4:1, and often manifests in older adults, with
an average age range of 41 to 61 years. The onset of erythroderma depends on the
underlying etiology, with the most common because being pre-existing dermatoses
(75.0%), including psoriasis (41.3%) and dermatitis (17.4%). According to a
study by Snigdha O et al., the most frequent type of dermatitis contributing to
erythroderma includes contact dermatitis (22%), allergic contact dermatitis
(5.5%), airborne contact dermatitis (3%), seborrheic dermatitis (3%), and
atopic dermatitis (5.5%). Other causes include drug reactions, malignancies,
systemic diseases, infections, and idiopathic conditions. Therefore,
erythroderma often has a differential diagnosis of psoriasis, which is the
leading cause of erythroderma.
Various factors affect the clinical
condition and prognosis, including patient age, underlying disease etiology,
medical history, erythroderma onset, and timing of therapy initiation. The
pathogenesis of erythroderma is linked to cytokine interaction and cellular
adhesion molecules. It is associated with interactions between IL-1, IL-2,
IL-8, ICAM-1, TNF, and interferon-gamma. These interactions increase epidermal
cell division and mitotic rate, causing a rise in germinative cell count,
reduced keratinocyte transit time in the epidermis, and subsequent exfoliation.
Retained skin scales contain amino acids, proteins, and nucleic acids typically
lost during desquamation. The pathogenesis of atopic dermatitis involves
increased IgE production, where high IgE levels in erythroderma are linked to allergies, further
inducing excessive interferon-gamma secretion. Moreover, erythroderma can
result in metabolic and physiological complications, including fluid and
electrolyte imbalance, heart failure, acute respiratory distress syndrome, and
secondary infections.
CASE STUDY
A 55-year-old, retired woman presented to
the Emergency Department at Rajawali Citra Hospital
in Bantul on September 5, 2023, with complaints of abdominal pain, vomiting,
and cough, along with itchy, dry, and flake skin on her face, neck, chest,
upper arms, and legs. The area around her eyebrows was still red, and her arms
and legs skin was dry. The patient regularly attended
monthly dermatology appointments, reporting that her skin was no longer itchy,
the flake had started to improve, and no new areas of skin were flake.
In May 2022, the patient visited the
hospital complaining of itching and flake skin on her neck, upper chest,
forearms, and legs. She enjoys gardening, which may have increased her exposure
to allergens. A week prior, she had experienced itching and sought treatment at
a local clinic, where she received oral medication and ointment, though she was
unaware of their names. Later, she self-administered methylprednisolone 4 mg
and cetirizine 10 mg, with slight improvement, prompting her to visit Rajawali Citra Hospital. She was diagnosed with
Photoallergic Contact Dermatitis (PCD) and received treatment with
methylprednisolone 16 mg once daily for three days, Mofacort
twice daily, and desoximetasone ointment. Biocream was applied to her arms and legs twice
daily. The patient reported improvement and did not return for follow-up. She
also had a history of diabetes mellitus, controlled with metformin 500 mg once
daily, and attended regular follow-ups for diabetes at the Internal Medicine
Clinic at Rajawali Citra Hospital.
In March 2023, the patient returned to the
Dermatology and Venereology Clinic at Rajawali Citra
Hospital with similar complaints of itching, redness, and flake skin all over
her body, which had recurred over the past four days. The itching, affecting
her head, face, neck, chest, arms, and legs, was continuous and disrupted her
daily activities due to pain. She was diagnosed with exfoliative dermatitis and
treated with methylprednisolone 62.5 mg intravenous injections every 24 hours,
cetirizine 10 mg once daily, mometasone 1% cream once daily for her face, desoximetasone ointment and Biocream
10 grams twice daily for her body, Carmed 10%
40 grams, and Caviplex once daily in the
morning. A week later, at follow-up, her symptoms had improved; there was no
new flake, though her face, neck, chest, arms, and legs remained red. Her
treatment was adjusted, replacing intravenous methylprednisolone with 8 mg oral
doses twice daily after meals.
In early May 2023, the patient revisited
the emergency department with neck stiffness, lower abdominal pain, cough, and
dry skin over her entire body. She also had yellow, crusted sores on her legs
that were painful and itchy, leading to her admission under the joint care of
the internal medicine and dermatology departments with a diagnosis of
erythroderma. During her hospitalization, she received intravenous
methylprednisolone 31.25 mg every 24 hours, loratadine 10 mg once daily, desoximetasone ointment twice daily, and fusidic acid cream twice daily on her leg wounds. After
three days, her condition improved, and she was discharged. At her follow-up,
she reported improved skin dryness, absence of itching, some remaining flake on
her arms, and no new wounds on her legs. She was diagnosed with seborrheic
dermatitis and given a compounded cream containing 1% salicylic acid, 3 grams
of glycerin, 30 grams of desoximetasone, and 30 grams
of Vaseline for twice-daily application over her entire body, along with 10 mg
loratadine once daily.
In June 2023, the patient reported
recurrent facial itching and redness, with dry, red, and slightly flake skin on
her arms, chest, and legs. Her treatment was continued, and she was referred to
UGM Academic Hospital for a skin biopsy. Histopathological examination (Figure
1) revealed features of spongiotic dermatitis, consistent with either allergic
contact dermatitis or seborrheic dermatitis.
Figure 1. A.
Psoriasiform pattern with elongation of rete ridges (yellow circle). B.
Epidermis with parakeratosis (green arrow). C. Epidermis with acanthosis (red
arrow). D. Dermis with infiltration of lymphocytes, plasma cells, and
eosinophils (blue arrow).
In July 2023, the patient reported that
her face remained red but was no longer itchy, and her body, arms, and legs had
no redness, though her skin felt dry. She received treatment with triamcinolone
12 mg, cetirizine 10 mg once daily, mometasone cream twice daily on her face,
and a compounded cream (desoximetasone and Vaseline)
applied twice daily over her body. She noted continued improvement and attended
biweekly follow-ups.
The current dermatological examination
showed erythematous patches with scales on the left supraorbital and nasal
areas (Figure 2A) and xerosis on the upper extremities, abdomen, and lower
extremities (Figures 2B-D).
Figure 2. (A) Erythematous patches with scales on
the left supraorbital and nasal regions. (B) Abdomen showing generalized
xerosis. (C) Upper extremities with xerosis on both the left and right palms.
(D) Lower extremities with xerosis on both the right and left feet.
Based on the patient's history, physical
examination, and supporting tests, she was diagnosed with exfoliative
dermatitis, showing clinical improvement, with a differential diagnosis of
allergic contact dermatitis (ACD). The patient received oral and topical
treatment with 10 mg loratadine once daily and desoximetasone
ointment applied twice daily.
Results and Discussion
The patient's gardening hobby involves
significant sun exposure, making her prone to sunburn or skin inflammation,
such as allergic photo contact dermatitis. This condition can cause eruptions
such as erythema, scaling, and desquamation in sun-exposed areas. In cases
where erythema and desquamation affect more than 90% of the body surface, a
diagnosis of erythroderma or exfoliative dermatitis can be established,
consistent with research by Sheikh F. et al., which found that the most common
causes of erythroderma are extensions of psoriasis and dermatitis.
The patient complained of itching on her
arms and legs during the examination. Dermatological findings revealed
erythematous patches with scales on the left supraorbital area and xerosis
across her limbs. The most common symptom of erythroderma is itching. Early
lesions of erythroderma begin with erythematous patches that spread, eventually
affecting nearly all skin areas. Within 2 to 6 days of onset, varied scaling
may appear. The skin becomes red, dry, and warm. During the acute phase of
erythroderma, lesions are characterized by widespread scaling and crusting,
while in the chronic phase, the scales are more minor and dry.
The type of scaling may suggest the underlying etiology: fine scales are
typically found in dermatitis, crusted scales in immunobullous
disease, exfoliative scales in drug reactions, and bran-like scales in
seborrheic dermatitis. In the chronic phase of erythroderma, lesions may evolve
into crusted erosions and secondary lichenification
from scratching and may also present as hyperpigmentation or hypopigmentation.
This patient's dermatological findings align with erythroderma, showing fine
scaling indicative of dermatitis as the underlying cause.
Diagnosis can be established through
history-taking, physical examination, and additional tests. Histopathological
examination from a skin biopsy is a diagnostic tool used to identify the
underlying etiology of erythroderma. Histopathological findings in erythroderma
typically show hyperorthokeratosis (thickening of the
keratin layer), acanthosis (epidermal thickening), and chronic perivascular
inflammatory cell infiltration with or without eosinophilia. In allergic
contact dermatitis, histopathology may show perivascular lymphocytic
infiltration, dermal edema, epidermal spongiosis, and exocytosis in the dermis.
Persistent lesions in chronic ACD may reveal reactive changes in the epidermis
(acanthosis, hyperkeratosis, parakeratosis) with minimal spongiosis and a mixed
inflammatory cell infiltrate in the dermis. The histopathological sample in
this case, taken in June 2023, showed features consistent with erythroderma and
ACD. Additional tests, such as a patch test to identify potential allergens,
are recommended to confirm ACD.
Erythroderma is characterized by
generalized erythema involving more than 90% of the body surface, sometimes
accompanied by erosions, crusting, and changes in hair or nails. The patient's
clinical presentation has shown improvement, with remaining lesions on the
supraorbital area and dryness on all four extremities. With lesions covering
less than 90% of the body, the diagnosis based on history, physical
examination, and histopathology is exfoliative dermatitis with clinical
improvement and allergic contact dermatitis as a differential diagnosis.
Type IV hypersensitivity is the reaction
in ACD. This involves two phases: sensitization, where an external substance
penetrates the skin and binds to skin proteins, forming an antigen complex that
induces an inflammatory response by activating the innate immune response via
keratinocyte-derived cytokines such as IL-1α, IL-1β, TNF-α,
IL-8, and granulocyte-macrophage colony-stimulating factor. The antigen is
presented by antigen-presenting cells (APCs), such as Langerhans cells and
dendritic cells, which migrate to the lymph nodes, where antigen-specific T
cells (Th1, Th2, Th17, and regulatory T cells) are activated, proliferate, and
circulate in the bloodstream. Naive T cells recognize the allergen molecules,
inducing effector and memory T cell formation. IL-1 and TNF-α also play a
role in erythroderma pathogenesis by increasing epidermal cell proliferation.
Erythroderma is a dermatological
emergency, with severity and underlying disease affecting its management.
Primary treatment includes maintaining body thermoregulation, such as by
applying warm compresses. Petrolatum, emollients, or low-potency topical steroids
can increase patient comfort. Petrolatum helps combat skin dryness by
maintaining stratum corneum hydration and enhancing desquamation. A moist
stratum corneum can better absorb topical therapy, and desquamation makes the
stratum corneum thinner, facilitating the migration of topical therapies.
Steroids aim to reduce acute inflammation in patients, addressing erythema and
pruritus. Antihistamines may also be used to reduce itching and anxiety. Key
considerations in erythroderma therapy include adequate nutrition and fluid
intake. Initial therapy when the patient was first diagnosed with erythroderma
(March 2023) included methylprednisolone 8 mg twice daily, cetirizine 10 mg
once daily, mometasone 1% cream once daily for the face, desoximetasone
ointment and Biocream 10 grams twice daily
for the entire body, Carmed 10% 40 grams
twice daily, and Caviplex once daily until
clinical improvement was noted. Treatment for contact dermatitis depends on the
phase: acute phases are managed with topical/systemic steroids and
antihistamines, while chronic phases are managed with moisturizing cream for
dry skin and added topical steroids. However, the primary approach is the
protection and avoidance of allergenic triggers. In this case, from the
emergency department visit in September 2023, the patient was treated with 10
mg loratadine once daily and desoximetasone ointment
twice daily. Desoximetasone is a medium-potency
corticosteroid with anti-inflammatory and anti-mitotic effects.
The patient continues to attend
dermatology and venereology clinic follow-ups at Rajawali
Citra Hospital, Bantul, every two weeks to a month.
Conclusion
We report a case of exfoliative dermatitis that demonstrated clinical
improvement with a well-regulated combination therapy
