Exfoliative dermatitis is widespread erythema and scaling of the skin caused by preexisting skin disorders, drugs, cancer, or unknown causes. Symptoms and signs are pruritus, diffuse erythema, and epidermal sloughing. Diagnosis is clinical. Treatment involves corticosteroids and correction of the cause.

Exfoliative dermatitis is a manifestation of rapid epidermal cell turnover. Its cause is unknown, but it most often occurs in the context of preexisting skin disorders (eg, atopic dermatitis, contact dermatitis, seborrheic dermatitis, psoriasis, pityriasis rubra pilaris), use of drugs (eg, penicillin, sulfonamides, isoniazid, phenytoin, barbiturates), and cancer (eg, lymphoma, mycosis fungoides, leukemia, and, rarely, adenocarcinomas). Up to 25% of patients have no identifiable underlying cause. Bacterial superinfection can complicate exfoliative dermatitis.

Symptoms and Signs

Symptoms include pruritus, malaise, and chills. Diffuse erythema initially occurs in patches but spreads and involves all or nearly all of the body. Extensive epidermal sloughing leads to abnormal thermoregulation, nutritional deficiencies because of extensive protein losses, increased metabolic rate with a hypercatabolic state, and hypovolemia due to transdermal fluid losses.

Diagnosis

• Clinical evaluation

Diagnosis is by history and examination. Preexisting skin disease may underlie the extensive erythema and suggest a cause. Biopsy is often nonspecific but is indicated when mycosis fungoides is suspected. Blood tests may reveal hypoproteinemia, hypocalcemia, and iron deficiency; however, these findings are not diagnostic.

Treatment

• Supportive care (eg, rehydration)
• Topical care (eg, emollients, colloidal oatmeal baths)
• Systemic corticosteroids for severe disease

The disease may be life threatening; hospitalization is often necessary. Any known cause is treated. Supportive care consists of correction of dehydration, correction of electrolyte abnormalities and nutritional deficiencies, and comprehensive wound care and dressings to prevent bacterial superinfection. Because drug eruptions and contact dermatitis cannot be ruled out by history alone, all drugs should be stopped if possible or changed. Skin care is with emollients and colloidal oatmeal baths. Weak topical corticosteroids (eg, 1 to 2.5% hydrocortisone ointment) may be used. Corticosteroids (prednisone 40 to 60 mg po once/day for 10 days, then tapered) are used for severe disease.

Prognosis depends on the cause. Cases related to drug reactions have the shortest duration, lasting 2 to 6 wk after the drug is withdrawn.

Last full review/revision October 2012 by Karen McKoy, MD, MPH