Clinicopathological study of exfoliative dermatitis

Introduction

Exfoliative dermatitis, also known of erythroderma, first described by Herba in 1868[1] is a reaction pattern, characterized by generalizec and confluent erythema with desquamatior affecting more than 90% of body surface and is usually accompanied by other systemic manifestation[2],[3] resulting in hemodynamic metabolic and biochemical derangements.

The aim of our study was to assess the demographic profile, aetiology, clinical feature and to correlate with histopathological findings.

Materials and Methods

The study was carried out among the outpatients of Dermatology and STD department as well as referrals and from other wards at SRMC & RI (DU), Porur from April 1998 to March 1999.

Twenty-five fresh cases of exfoliative dermatitis involving more than 90% of the body surface area were included in the study. A detailed history regarding onset, drug intake, preexistinc dermatoses and evidence of systemic diseases were noted. Complete general physical examination, systemic examination and a thorough search for any internal malignancy were made in all cases.

All relevant investigations including skin biopsy and patch testing were done in all the patients during quiescent phase using Indian Standard Series.

Results

The age group affected ranged from 5 days to 72 years with a peak incidence between 21-30 years (24%). There were no patients between the age of 51-60 years. The male : female ratio was 1.5:1. The duration of illness ranged from 4 days to 10 years with a mean of 1.44 years.

Scaling (100%), pruritus (80%) and erythema (80%) followed by nail changes (64%) and shivering (60%) were the commonest clinical manifestations [Table - 1] & [Table - 2]

Psoriasis and drug reactions were the commonest causes in 32% and 24% respec-tively followed by ec-zema, hereditary disorders and pemphigus foliaceus [Table - 3].

Dapsone, ibuprofen, diclofenac, carbamazepine, chlorpromazine and siddha preparations were the drugs incrimi-nated in the study.

Lamellar ichthyosis ant Netherton′s syndrom, were the hereditar disorders encounterec and carcinoma posteric third of the tongue wa the malignancy notice in the study.

The laboratory abnormalities notice were anaemia (20% raised ESR (20%) an hypoproteinemia with altered A/G ratio (12%). Patch testing with neomycin was positive in one patient and ELISA for HIV was positive in another patient. Scraping for fungal elements was also positive in this immuno-compromised patient.

Thirty-six percent of HPE reports were consistent with psoriasis, 24% with non-specific dermatitis and 8% each of erythema multiforme and pemphigus foliaceus. One patient with extensive dermatophyte infection showed PAS positive spores and hyphae in stratum corneum. The patient with Netherton′s syndrome showed the characteristic features of PAS positive material in statum corneum and hair examination in the same patient revealed trichorrhexis invaginata.

Discussion

There is no dearth of published studies about erythroderma in the literature. However, aetiological factors depend largely on the population studied, though clinical presentation may essentially be the same. Hence we conducted this study to assess any variation in clinical, aetiological and histopathological profile of our patients from others.

Various studies over the years have shown that there has been a steady decrease in the incidence of drug reactions. In one recent study, it was as low as 5.5%.[4] However drug reactions still come higher up in our list of causes. This is hardly surprising because in India most of the medications are still available over the counter and also people are not aware of the hazards of taking indigenous treatment.

The percentage of malignancy-induced exfoliative dermatitis was much lower compared to other studies especially Nicolis et al[2] and King et al[5] which showed 21 % and 20% respectively. This probably emphasizes the need for a more extensive workup to rule out occult malignancies especially in elderly age group.

The histopathological examination in our patients was also not rewarding since all the patients showed features of non-specific dermatitis and psoriasis.

Previous studies have shown that erythroderma a distressing disorder, seldom poses a risk to patient′s life.[6] However in our group, 2 patients died of related causes like cardiac failure and septicaemia. This emphasizes the need for active monitoring of the patients for any metabolic (or) infective complications.