Year : 2021 Month : September Volume : 10 Issue : 37 Page : 3213-3219

A Clinico-Etiological Study of Erythroderma in Adults in a Tertiary Care Centre

 

Jagaragallu Amrutha1, Narasimha Rao Netha Gurram2, Padmaja Pinjala3, Bhumesh Kumar Katakam4, Rajeev Singh Thakur5

1, 2, 3, 4, 5 Department of Dermatology, Venereology, Leprosy,
Gandhi Medical College, Secunderabad, Telangana, India.

CORRESPONDING AUTHOR

Dr. Amrutha Jagaragallu, Gandhi Medical College, Secunderabad, Telangana, India.
Email : j.amrutha05@gmail.com

ABSTRACT

BACKGROUND

Erythroderma is a clinical entity that may cause severe systemic manifestations. The difficulty with erythroderma lies in finding the underlying aetiology. It is imperative to demonstrate precise aetiology whenever possible so that distinct therapy may be initiated. At times, despite finding the aetiology, relapses constitute a great menace. The purpose of our study was to assess the clinical profile and aetiology of erythroderma. Besides, the study also illustrated factors leading to relapses; such studies are rare in literature.

 

METHODS

This hospital-based, cross-sectional study included 88 patients of erythroderma of either sex and age more than 18 years; their clinical, laboratory, histopathological findings, treatment and outcome were studied.

 

RESULTS

The mean age of onset was 47.3  12.35 years with the male to female ratio being 2.38:1. The most common cause of erythroderma was pre-existing dermatoses (67 %) followed by drugs (10.2 %), infections (3.4 %), malignancies (4.54 %), and idiopathic (14.7 %). Psoriasis was the predominant aetiology (45.4 %) among the pre-existing dermatoses with a maximum number of relapses (P = 0.02). Psoriasis was significantly associated with pruritus (P = 0.001), subungual hyperkeratosis (P = 0.0001), palmoplantar keratoderma (P = 0.001). Clinicohistological association was found in 64.6 % of cases. Mortality was seen in 6.8 % of cases.

 

CONCLUSIONS

As in previous studies, pre-existing dermatoses were the most common causes in our study; albeit, a special emphasis on factors leading to relapses was given to prevent further episodes. The most common factor of relapse was uncontrolled comorbid disorders (diabetes and hypertension) followed by medication nonadherence. Hence, our study suggests a need for more effective comorbidity management and creating awareness regarding judicial use of drugs which can go far in preventing mortality and morbidity.

 

KEY WORDS

Erythroderma, Adults, Aetiology, Relapses, Comorbidities.

BACKGROUND

Erythroderma is a generalized inflammatory disorder of the skin manifesting with erythema and scaling affecting more than 90 % of the skin surface.1 It is one of the few dermatological conditions requiring hospitalization and multisystem management. Erythroderma is considered a complex system that may be the result of many different causes. The diagnosis of the underlying cause may be very difficult but it is important to find aetiology for the appropriate intervention of each case.

 

 

Objectives

To evaluate demographic profile, clinical features, aetiology of erythroderma and correspond the clinical diagnosis with histopathology.

METHODS

This cross-sectional study was conducted between January 2017 and June 2019 (30 months) at a tertiary care teaching hospital located in Southern India. 88 successive erythroderma patients aged above 18 years were included in the study. Pregnant and lactating women were excluded from the study. The study was recognized by the institute scientific and ethics committees and written informed consent was procured from all patients.

Study patients were enlisted from dermatology outpatient clinics and referrals from other departments and convenience sampling was followed. All patients were admitted and were evaluated with detailed history and complete physical examination. History included the onset and evolution of erythroderma, history of pre-existing dermatoses, previous episodes of erythroderma, aggravating factors, comorbidities and drug intake. A detailed clinical examination was done to know the various clinical manifestations and also find out the possible causes for the erythroderma.

History of silvery scaly plaques and heavier involvement in body parts where psoriasis was common helped in making out psoriatic erythroderma. Typical nail changes of psoriasis and psoriatic arthritis if present are clues to psoriasis. Strong history of contact allergy, presence of previous eczematous lesions and also severe oozy lesions will help to diagnose the allergic contact dermatitis as the cause of erythroderma, which was confirmed by patch testing. Ingestion of suspected drugs before the onset and acute onset with fever will help in the diagnosis.

Diagnosis of idiopathic erythroderma could be made when the condition is extending over 1 month in an elderly with severe pruritus with palmoplantar keratoderma. Cutaneous lymphoma presents with similar findings of idiopathic erythroderma, keen histopathological examination and follow-up biopsy will help to make out the diagnosis.

Laboratory investigations such as complete hemogram, blood glucose, renal function tests, liver function tests, serum electrolytes, erythrocyte sedimentation rate, serum protein levels, urine microscopy, serum markers for viral hepatitis B and C and HIV antibody testing were performed. Wherever necessary, chest radiograph, ultrasound, peripheral blood smear, fine needle aspiration cytology of lymph nodes, patch testing, microscopy for scabies mite and fungus were done. Skin biopsy for histopathological examination was performed in 62 cases (70.45 %). We have also examined data concerning management, outcome, relapses and complications when available.

 

 

Statistical Analysis

The findings were recorded on a specially designed master chart and statistical tests were done using Epi info software version 7.2.2.6 and analyses were done at a 5 % level of significance and a P-value of < 0.05 was considered significant. Chi-square test was applied to obtain the P-value.

RESULTS

The mean age of onset was 47.3  12.35 years with the age of the patients ranging from 21 to 78 years. The majority of the patients belonged to the age group of 40 - 49 years (38 cases) (43.1 %) and a minimum number of patients in 70 - 79 years group (4 cases) (4.54 %). There were 62 males (70.5 %) and 26 females (29.5 %) with a male to female ratio being 2.38:1, showing male preponderance.

The mean duration of onset of erythroderma was 46 days (median = 60 days) (range: 1 day–18 months). Progression of the disease was in less than 6 - 8 weeks in 72 patients (81.8 %); albeit, 12 patients showing sudden progression within 3 - 4 days were seen in psoriasis. A longer duration of more than one year was seen in cutaneous lymphoma and psoriasis. In the study, psoriasis was the entity with a varied duration of onset ranging from few days to more than one year.

In the study, comorbidities were recorded in 58 patients (65.9 %). The most common comorbidities documented were hypertension (42 patients), diabetes (33 patients), tuberculosis (three patients), HIV / AIDS (four patients) and epilepsy (four patients). 75 % of patients with psoriasis (30 patients out of 40) had at least one comorbidity in their past medical history.

Pre-existing dermatoses were recorded in 27 patients (30.6 %) which comprised psoriasis (22 patients), eczema (five patients).

Table 1 illustrates the characteristics of the patients and a summary of the results of the study.

 

 

Clinical Features and Laboratory Investigations

Besides generalized erythema and scaling, clinical features included pruritus (49 / 88 patients; 55.6 %), shivering (26 / 88 patients; 29.5 %), malaise (41 / 88 patients; 46.5 %), pedal oedema (43 / 88 patients; 48.8 %), fever (18 / 88 cases; 20.4 %), palmoplantar keratoderma (55 / 88 patients; 62.5 %), nail changes (64 / 88 patients; 72.7 %), lymphadenopathy (28 / 88 patients; 31.8 %). (Figure 1a,1b). Hypoalbuminemia (16 / 88 patients; 18.1 %) is attributed to loss of proteins in the form of scales and hepatic insufficiency.

 

 

Aetiology

In the study, patients were categorized into five etiologic groups as illustrated in Figure 2: (1) Pre-existent dermatoses (66.9 %) (2) infections (3.4 %) (3) drug reactions (10.2 %) (4) malignancy (4.5 %) (5) idiopathic or undetermined (14.7 %). Pre-existing dermatoses comprising psoriasis and eczemas contributed the highest percentage of erythroderma as seen in 59 patients (66.9 %). Psoriasis was the most common pre-existing dermatosis causing erythroderma (40 / 88 patients; 45.4 %) (Figure 1c). Erythroderma had arisen on pre-existing longstanding

psoriasis in 22 patients with a mean period of 557 days and median period of 90 days (ranges: 4 days and 7 ½ years). Acute onset of erythroderma was seen in 12 patients and all of them had a history of psoriatic arthritis (P = 0.02). 14 psoriasis patients had relapses and among them, 10 patients had significantly longer duration of psoriasis (P = 0.002) [mean = 2.5 years and median = 1 1 / 2 year (range: 1–7years)].