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ORIGINAL ARTICLE
Year : 2022 | Volume
: 42
| Issue : 2 | Page : 81-91
Clinicopathological assessment of patients with erythroderma
Mohammed Abu El-Hamd MD 1, Sheren F.M. Ahmed2, Dina G.A. Ali1, Hanan Abd-Elrady Assaf1
1 Department of Dermatology, Venereology and Andrology, Faculty of Medicine, Sohag University, Sohag, Egypt
2 Department of Pathology, Faculty of Medicine, Sohag University, Sohag, Egypt
Correspondence Address:
Mohammed Abu El-Hamd
Department of Dermatology, Venereology and Andrology, Faculty of Medicine, Sohag University, Sohag University Street, Sohag City 82524, Sohag
Egypt
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ejdv.ejdv_32_21
Background Erythroderma is a rare disease, characterized by generalized erythema and scaling of the skin.
Aims The aim of this study was to clinicopathologically assess patients with erythroderma who attended the Department of Dermatology at the Faculty of Medicine, Sohag University, Upper Egypt.
Patients and methods This was a cross-sectional clinical research study that was carried out on 33 patients with erythroderma. All of the patients were subjected to complete medical history taking and general and dermatological examinations. All of the patients were subjected to laboratory, radiological, and cutaneous histopathological evaluations.
Results The mean age of the patients was 46.86 years. According to the clinical and histopathological findings, the erythrodermic patients were categorized into 26 (78.78%) patients who had preexisting dermatoses, four (12.12%) patients had malignancies, and three (9.1%) patients had drug reactions. Moreover, there was moderate and perfect interrater reliability agreement between clinical and histopathology evaluations in the diagnosis of different etiological causes of erythroderma.
Limitations A small sample size and small number of included patients were the limitations of the study.
Conclusion This study concluded that the main causes of erythroderma were preexisting dermatoses followed by malignancies and drug reactions. Psoriasis was the main preexisting dermatoses in erythrodermic patients. Clinical and histopathology evaluations are essential for accurate diagnosis of different etiological causes of the erythroderma.
Keywords: erythroderma, erythrodermic psoriasis, histopathological evaluations, psoriasis
Erythroderma is an inflammatory disorder in which erythema and scaling are present in a generalized distribution, affecting more than 90% of the body surface area [1]. Hasan and Jansen [2] reported that the annual incidence of erythroderma was 1–2 per 100 000 patients. Moreover, the incidence of erythroderma in a large prospective clinical study from the Indian subcontinent was 35 per 100 000 dermatologic patients [3].
Numerous factors have been ensnared as triggers for erythroderma and may be categorized into numerous general groups like preexisting dermatoses, medications, malignancies, and idiopathic [4]. The commonest cause of erythroderma was preexisting cutaneous diseases, such as psoriasis, eczematous dermatoses, pityriasis rubra pilaris, lichen planus acquired ichthyosis, cutaneous lupus, scabies, bullous pemphigoid, pemphigus foliaceus, actinic dermatoses, and actinic keratosis [4],[5],[6],[7].
The most common medications implicated in erythroderma were antiepileptic drugs (phenytoin, carbamazepine, and phenobarbital), antituberculosis drugs (rifampicin, isoniazid, ethambutol, and pyrazinamide), antibiotics (sulfonamide, penicillin, and vancomycin), lithium, allopurinol proton pump inhibitors, and anti-human immunodeficiency virus agents [5],[6],[7].
Erythroderma is a clinical diagnosis [8]. Laboratory findings are nonspecific, as erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are elevated in most of the patients [4]. Anemia, leukocytosis, eosinophilia, and abnormal serum protein levels were found in some patients [5]. Direct immunofluorescence was helpful in the diagnosis of several bullous or connective tissue diseases [5]. Skin biopsy was routinely used with clinical findings to establish the underlying causative factor of erythroderma [8].
The aim of this study was a clinicopathological assessment of patients with erythroderma who attended the Department of Dermatology at the Faculty of Medicine, Sohag University, Upper Egypt.
Patients and methodsStudy design and populations
This study was a cross-sectional clinical research. It included 33 patients with erythroderma who were admitted to the Department of Dermatology, Faculty of Medicine, Sohag University, Upper Egypt, in the period between January 2018 and December 2019.
Ethical consideration
This study was approved by the Research and Ethical Committee at the Faculty of Medicine, Sohag University, Egypt. Informed consent was obtained from all patients after explaining the details of the study.
Patient evaluation
Medical history: all of the patients were subjected to full medical history taking, it included; personal history, present history (onset, course, and duration of the disease), history of precipitating factors of erythroderma (history of preexisting skin diseases, history of drug intake, psychological trauma, previous attack of erythroderma, and pregnancy), history of medical diseases, history of medications, and family history of similar conditions.General medical examination: all of the patients were examined for pulse, blood pressure, and temperature.Dermatological examination: all of the patients were examined to confirm the diagnosis of erythroderma and to detect any cutaneous diseases associated with erythroderma, which included skin, hair, nail, and mucous membrane examinations.Photographing assessment: all of the patients were assessed by a photograph taken by a smartphone camera Samsung galaxy J7 about 16 megapixels.Investigation: all of the patients were assessed with the following investigations to detect any abnormalities.Laboratory investigations included complete blood picture, ESR, CRP, serum electrolytes, blood sugar, liver function tests, and kidney function tests.Radiological investigations included chest radiography, abdominal ultrasound, and ECG.Biopsy: skin punch biopsies (3.5-mm size) were taken from the skin lesions. The biopsies were fixed in 10% neutral formalin, and paraffin-embedded serial sections were prepared for histopathological examination. Sections of 4 μm thick from formalin-fixed paraffin-embedded tissue blocks were deparaffinized in xylene and then rehydrated through downregulated alcohols (100, 80, 70, and 50% 1 min for each), then rinsed in distilled water followed by running tap water for 3–5 min. The slides were stained with hematoxylin for 5–7 min, washed in running tap water, and then stained with eosin for 3–5 min followed by running tap water. The slides were dehydrated in upgraded concentrations of ethanol (50% ethanol, 70, 80, and 100%, 1 min for each), and then cleared in xylene and mounted with distyrene plasticizer xylene and cover slipped. Slides were examined by light microscopy to confirm the diagnosis.Immunohistochemistry evaluations (LCA, CD-3, and CD-5) were done for some cases that suggested having mycosis fungoides.Statistical analysis of data
Data were analyzed using the IBM SPSS software package version 20.0 (IBM Corp., Armonk, New York, USA). Quantitative data were expressed as means±SD, median, and interquartile range. Qualitative data were expressed as number and percentage. McNemar test was used for comparing the results of clinical and histopathological diagnosis. Cohen’s kappa and its significance were calculated to assess the agreement of different methods of diagnosis. A 5% level was chosen as a level of significance in all statistical tests used in the study.
ResultsThis study included 33 erythrodermic patients. The mean age of the patients was 46.86±21.78 years. A total of 19 (57.58%) patients were males and 14 (42.42%) patients were females, with a male to female ratio of 1.4 : 1, showing a male predominance. Moreover, 16 (48.48%) patients were living in suburban areas, nine (27.27%) patients were living in urban areas, and eight (24.24%) patients were living in rural areas. In addition, 11 (33.33%) patients were housewives and 11 (33.33%) patients were manual workers; 21 (63.64%) patients were married, eight (24.24%) patients were widow, and three (9.09%) patients were single; and 10 (30.3%) patients were smokers.
The distribution of erythrodermic patients according to the age was as follows: four (12.12%) patients were aged 0–19 years, nine (27.27%) patients were aged 20–30 years, eight (24.24%) patients were aged 40–59 years, 10 (30.30%) patients were aged 60–79 years, and two (6.06%) patients were aged 80–99 years.
According to the clinical medical history of the erythrodermic patients, 26 (78.79%) patients had a gradual onset and 24 (72.73%) patients had a progressive course. The duration of erythroderma ranged from 7 to 15 days, with a mean duration of 11.48±8.74 days. Erythema and scaling presented in 33 (100%) patients, 19 (57.58%) patients had itching, 17 (51.52%) patients had malaise, seven (21.21%) patients had a fever, and one (3.03%) patient had oliguria.
The most common systemic diseases recorded with erythrodermic patients were as follows: 11 (33.33%) patients had systemic hypertension, five (15.15%) patients had diabetes mellitus, three (9.1%) patients had psoriatic arthropathy, one (3.03%) patient had rheumatoid arthritis, one (3.03%) patient had systemic lupus erythematous, and one (3.03%) patient had ischemic heart disease.
The precipitating factors of erythroderma were as follows: 17 (51.5%) patients had history preexisting dermatoses, nine (27.27%) patients had a history of drug intake, eight (24.24%) patients had a history of infection, three (9.1%) patients had a history previous attack of erythroderma, and two (6.1%) patients had a current pregnancy ([Table 1]).
Table 1 Distribution of the erythrodermic patients according to the precipitating factors (N=33)On general examination of erythrodermic patients, 13 (39.4%) patients had hypertension, eight (24.24%) patients had a fever, and two (6.1%) patients had tachycardia. On dermatological examination of erythrodermic patients, 33 (100%) patients had erythema and scaling in more than 90% of body surface area, 10 (30.3%) patients had palmoplantar keratoderma, five (15.15%) patients had lymphadenopathy, and five (15.15%) patients had edema.
On hair and nail examination of erythrodermic patients, 26 (78.79%) patients had a scaly scalp, three (9.09%) patients had diffuse alopecia, three (9.09%) patients had pustular lesions in the scalp, and one (3.03%) patient had a loss of an outer third of the eyebrow. A total of 15 (45.45%) patients had nail changes, 13 (39.39%) patients had subungual hyperkeratosis, eight (24.24%) patients had nail dystrophy, five (15.15%) patients had pitting, two (6.06%) patients had longitudinal striation, and one (3.03%) patient had yellow nail discoloration.
On mucous membrane examinations of erythrodermic patients, six (18.18%) patients had oral candidiasis, one (3.03%) patient had hyperpigmented macule at hard palate, one (3.03%) patient had oral ulcers, and one (3.03%) patient had a scrotal tongue.
The main laboratory findings of erythrodermic patients were as follows: 21 (63.64%) patients had anemia, 13 (39.4%) patients had microcytic anemia, 16 (48.48%) patients had hypochromic anemia, 14 (42.42%) patients had eosinophilia, 12 (36.36%) patients had leukocytosis, 17 (51.52%) patients had lymphopenia, and 27 (81.82%) patients had thrombocytopenia.
A total of 21 (63.64%) patients had hyponatremia, one (3.03%) patient had hyperkalemia, one (3.03%) patient had hypokalemia, and three (9.1%) patients had hypocalcemia.
Overall, seven (21.21%) patients had abnormal alanine aminotransferase, five (15.15%) patients had abnormal aspartate aminotransferase, four (12.12%) patients had hyperbilirubinemia, 24 (72.73%) patients had hypoproteinemia, and 19 (57.58%) patients had hypoalbuminemia.
Moreover four (12.12%) patients had mild increased ESR, four (12.12%) patients had marked increased ESR, three (9.1%) patients had moderate increases ESR, seven (21.21%) patients had increased CRP, one (3.03%) patient had abnormal serum creatinine, four (12.12%) patients had hypoglycemia, and two (6.1%) patients had hyperglycemia.
The main chest radiograph findings of the erythrodermic patients were observed in 29 (87.87%) patients, 10 (34.48%) patients had cardiomegaly, four (13.79%) patients had accentuated bronchovascular marking, two (6.9%) patients had elevated copula, and one (3.45%) patient had pleural effusion. The main abdominal ultrasonography findings of the erythrodermic patients were as follows: 15 (45.45%) patients had mildly enlarged liver, two (6.06%) patients had both kidneys of echogenic grade, and 15 (45.45%) patients had mildly enlarged liver.
The clinical diagnoses of erythrodermic patients were as follows: 26 (78.78%) patients had preexisting dermatoses [14 (42.4%) patients had psoriasis, seven (21.2%) patients had eczema, one (3.03%) patient had pityriasis rubra pilaris, one (3.03%) patient had pemphigus foliaceous, and one (3.03%) patient had disseminated candidiasis]. Moreover, six (18.18%) patients had malignancies (mycosis fungoides), and three (9.1%) patients had drug reactions ([Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5]).
Figure 1 (a–c) A 65-year-old male patient presented with erythema and scaling all over the body. (d–f) Histopathology with low (×100) and high (×400) power field showing epidermal change, for example, psoriasiform hyperplasia (regular acanthosis, hyperkeratosis, and parakeratoses with hypogranulosis), elongation of rete ridges, and suprapapillary thinning, and dermal change, for example, dilated superficial dermal capillaries with mild perivascular mononuclear cell infiltrates (erythrodermic psoriasis).
Figure 2 (a, b) A 33-year-old pregnant female patient presented with erythema and scaling all over the body. (c–f) Histopathology with low (×100) and high (×400) power field showing epidermal changes, for example, psoriasiform hyperplasia (regular acanthosis, hypogranulosis, hyperkeratosis and parakeratosis), multiple neutrophilic cellular collections within parakeratotic scale, and suprapapillary thinning, and dermal changes, for example, dilated superficial dermal capillaries and moderate infiltrate of neutrophils, lymphocytes, and histiocytes (erythrodermic pustular psoriasis).
Figure 3 (a–d) A 39-year-old female patient presented with erythema and scaling all over the body. (e, f) Histopathology with low (×100) and high (×400) power field showing epidermal changes, for example, psoriasiform hyperplasia of the epidermis (acanthosis and hyperkeratosis) with minimal spongiosis and mild hyperkeratosis with scarce neutrophilic infiltrates, and dermal changes, for example, mild edema of the papillary dermis with mild superficial perivascular inflammatory infiltrate of lymphocytes, plasma cells, histiocytes, and few neutrophils (erythrodermic seborrheic dermatitis).
Figure 4 (a–c) An 82-year-old male patient presented with erythema and scaling all over the body. (d–f) Histopathology with low (×100) and high (×400) power field showing epidermal changes, for example, irregular acanthosis with normal granular layer and overlying hyperkeratosis with parakeratotic foci, and dermal changes, for example, superficial mild perivascular mononuclear cellular infiltrates (erythrodermic dermatitis).
Figure 5 (a) An 81-year-old female patient, presented with severe itching erythroderma. (b, c) Histopathology with low (×100) and high (×400) power field showing psoriasiform hyperplasia, intraepidermal lymphocytes with minimal spongiosis with multiple small Pautrier-like microabscesses, and mild parakeratosis. Patchy lichenoid infiltrate of lymphocytes within sclerotic papillary dermis. Some of lymphocytic infiltrates appear large with irregular nuclear contour and line up the overlying epidermis (Mycosis fungoides). (d–f) Positive immunophenotyping LCA (d), CD-3 (e), and CD-5 (f) markers.The histopathological diagnoses of the erythrodermic patients were as follows: 26 (78.78%) patients had preexisting dermatoses [16 (48.48%) patients had psoriasis, eight (24.24%) patients had eczema, one (3.03%) patient had pityriasis rubra pilaris, and one (3.03%) patient had pemphigus foliaceous], four (12.12%) patients due to malignancies (mycosis fungoides), and three (9.1%) patients had drug reactions ([Table 2] and [Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5]).
Table 2 Comparison between clinical diagnosis and histopathological diagnosis of erythroderma (N=33)There were no statistically significant differences between clinical and histopathological evaluations in the diagnosis of different etiological causes of erythroderma ([Table 2]).
According to clinical and histopathological findings, the erythrodermic patients were categorized into the following: 26 (78.78%) patients had preexisting dermatoses, four (12.12%) patients had malignancies, and three (9.1%) patients had drug reactions.
Moreover, there was moderate and perfect interrater reliability agreement between clinical and histopathological evaluations in the diagnosis of different etiological causes of erythroderma ([Table 3]).
Table 3 Agreement of histopathological examination with clinical examination in the diagnosis of erythroderma (N=33) Discussion The current study reported that the mean age of the included 33 patients with erythroderma was 46.86 years. This finding was in agreement with Akhyani et al. [6], who found that the mean age of the patients with erythroderma was 46.2 years.
In contrast to this finding, Hulmani et al. [9], Rym et al. [10], César et al. [4], Khaled et al. [11], and Tan et al. [7] reported that the mean age of the erythrodermic patients was 52.3, 53.78, 54.4, 55.13, and 66 years, respectively.
The male to female ratio in this study revealed a slightly higher prevalence in men than in women, with a male to female ratio of 1.4 : 1, which was in agreement with many previous studies [4],[6].
It has been reported that erythroderma was three times more in males [3],[12],[13]. Hulmani et al. [9] found very high male predominance, and the ratio of male to female was 14 : 1. This reason could be explained by the habit of alcohol intake and predominant outdoor work by male patients, which are known to exacerbate psoriasis and eczemas, respectively. However, Parisi et al. [14] showed a higher incidence of erythroderma in women than in men.
This study found that most of the patients had a gradual onset of erythroderma. This finding was in agreement with many previous studies [9],[11],[15].
In this study, all patients had generalized erythema and scaling. These findings were in agreement with previous studies [4],[9],[16]. However, Sudho et al. [17] reported that scaling was seen in 100% and erythema was seen in 80% of the erythrodermic patients. Pal and Haroon [18] reported that scaling was seen in 84.4% of the patients.
The erythema is caused by dilatation and proliferation of the cutaneous blood vessels and the possible interactions between lymphocytes and endothelium cells, whereas scaling is caused by the variable alterations in the epidermis such as enhanced epidermal turnover, parakeratosis, and acanthosis [17].
In this study, pruritus was recorded in 19 (57.5%) patients. In contrast to this finding, Khaled et al. [11], Jowker et al. [19], Hulmani et al. [9], César et al. [4], and Akhyani et al. [6] reported pruritus in 56, 64.7, 86.6, 97.1, and 97.5% erythrodermic patients, respectively.
The pathogenesis of pruritus in erythrodermic patients is not completely clear, possibly owing to the interaction among several cytokines and cellular adhesion molecules in the skin [20].
The current study reported that the precipitating factors of erythroderma were as follows: 51.5% of patients had history of preexisting dermatoses, 27.27% of patients had a history of drug intake (captopril, diclofenac, amitriptyline, carbamazepine, and penicillin), 24.24% of patients had a history of infection, 9.1% patients had a history previous attack of erythroderma, and 6.1% of patients had a current pregnancy.
In contrast to these findings, it has been reported that the most common precipitating factors observed in erythrodermic patients were winter season followed by intake of medications (phenytoin, carbamazepine, nitrazepam, glipizide, dapsone, and ayurvedic medications), contact with cement, and previous episodes of erythroderma [9],[21].
This study reported several systemic diseases associated with erythrodermic patients: 33.33% patients had systemic hypertension, 15.15% of patients had diabetes mellitus, 9.1% of patients had psoriatic arthropathy, 3.03% of patients had rheumatoid arthritis, 3.03% of patients had systemic lupus erythematous, and 3.03% of patient had ischemic heart disease. In contrast to this study, César et al. [4] reported numerous systemic diseases in erythrodermic patients: 14.6% of patients had systemic hypertension, 9.7% of patients had diabetes mellitus, 8.7% of patients had congestive heart failure, 6.8% of patients had dyslipidemia, 4.9% of patients had chronic kidney disease, and 4.9% of patients had epilepsy.
This study found that seven (21.2%) patients with erythroderma had a fever during the episode (temperature ≥38°C). In contrast to this finding, King et al. [22], Yuan et al. [14], Hulmani et al. [9], and César et al. [4] reported fever in 33.0, 37.8, 43.3, and 54.4% of erythrodermic patients, respectively. The pathophysiology of fever in erythroderma is not completely understood, probably owing to temperature dysregulation [20].
In this study, lymphadenopathy was found in 15% of erythrodermic patients and 45% of patients had hepatomegaly. In contrast to this finding, Rym et al [10], Akhyani et al. [6], Tan et al. [7], César et al. [4], Pal and Haroon [18], and Hulmani et al. [9] reported lymphadenopathy in 26.3, 31.3, 32.9, 40.8, 55.5, and 56.6% of erythrodermic patients, respectively.
Lymphadenopathy has been reported to be associated with cutaneous T-cell lymphoma, drug reactions, and psoriasis [9],[23]. In addition, it has been found that lymphadenopathy could be owing to drug hypersensitivity or malignancy. If cutaneous pathology mimics cutaneous T-cell lymphoma, it can be very financially to differentiate a drug-induced erythroderma from erythroderma associated with malignancy [24].
In contrast to this finding, Tan et al. [7], Rym et al. [10], Hulmani et al. [9], and César et al. [4] reported hepatomegaly in 1, 2.5, 13.3, and 41.7% of erythrodermic patients, respectively. Hepatomegaly has been reported in association with erythroderma caused by drug intake [4],[9].
This study reported pitting pedal edema in 12% of erythrodermic patients. In contrast to this finding, Yuan et al. [15], Tan et al. [7], Rym et al. [10], César et al. [4], Huma et al. [21], and Hulmani et al. [9] found pedal edema in 14.4, 19.6, 21, 56.3, 64, and 70% of erythrodermic patients, respectively. It has been reported that pedal edema may be related to enhancing the cutaneous blood flow and enhanced capillary permeability secondary to hypoproteinemia [3],[13].
This study reported that palmoplantar keratoderma was presented in 30.3% of erythrodermic patients. In contrast to this study, Hulmani et al. [9] found palmar keratoderma in 73.3% of the patients and plantar keratoderma in 40% of the patients. However, César et al. [4] found palmoplantar keratoderma in 50.5% of the patients. It may be associated with psoriasis, eczema, and pityriasis rubra pilaris.
Nail changes were observed in 45% of erythrodermic patients in this study. The most common nail changes were ridging of the nail, subungual hyperkeratosis, pitting, nail discoloration, and dystrophy.
In contrast to these findings, several studies reported that nail changes were observed in 70% of the erythrodermic patients. The most common nail changes were ridging of nail, subungual hyperkeratosis, pitting, Beau’s lines, nail discoloration, and nail dystrophy [9],[17],[18],[21].
Of erythrodermic patients of this study, 18.18% of patients had oral candidiasis, 3.03% of patient had hyperpigmented macule at hard palate, 3.03% of patients had oral ulcers, and 3.03% of patients had a scrotal tongue. Incomparable to this study, Hulmani et al. [9] found oral mucosal congestion and erosion in 13.3% of erythrodermic patients and they were of drug-induced erythroderma.
Anemia was reported in 64% of erythrodermic patients of this study. Incomparable to this finding, Rym et al. [10], César et al. [4], Bandyaopadhyay et al. [16], Hulmani et al. [9], and Pal and Haroon [18] reported in 29, 30.1, 48, 50, and 72% of erythrodermic patients, respectively. It has been reported that mild anemia with low hematocrit values was thought to be due to folic deficiency, iron deficiency, and a chronic inflammatory state. More severe anemia is unusual. Leukocytosis was observed in 36% of erythrodermic patients in this study. This was in agreement with several previous studies which reported that leukocytosis was observed in 40% of erythrodermic patients [2],[9],[16],[21].
In this study, eosinophilia was seen in 42.3% of erythrodermic patients. Incomparable to this finding, Hasan and Jansen [2], Hulmani et al. [9], Huma et al. [21], and Tan et al. [7] reported eosinophilia in 48, 53.3, 56, and 58.2% of erythrodermic patients, respectively.The cause of eosinophilia is the inflammatory process, which generates a cascade and network of chemotactic factors and triggers the mobilization and stimulation of the inflammatory cells, including eosinophils, which may play a role in the clinical evolution of erythrodermic patients [25],[26],[27].
Their stimulation includes the release of the granule constituents, such as eosinophilic cationic protein and reactive oxygen species synthesis [28].
In this study, hypoproteinemia was seen in 72% of patients. Incomparable to this finding, Botella-Estrada et al. [12], Hulmani et al. [9], and Huma et al. [21] found hypoproteinemia in 34, 63.3, and 64% erythrodermic patients respectively. The hypoproteinemia could be owing to continuous protein loss through shed scaling, enhanced basal metabolic rate, chronic malnutrition, reduced liver synthesis, or dilution due to hypervolemia [29],[30].
Increased serum creatinine in this study was seen in 3.03% of erythrodermic patients. However, Huma et al. [21] observed increase serum creatinine in 8% of erythrodermic patients who were also known to be diabetics; preexisting diabetes could be the cause for this finding. A study by Rafael et al. [31] found increased serum creatinine in 41% of erythrodermic patients.
In this study, serum electrolyte imbalances in the form of low sodium levels were seen in 63.6% of the patients, and low potassium levels in 3% of the patients. In contrast to this finding, Hulmani et al. [9] reported that low sodium levels were seen in 50% of the patients and low potassium levels in 5% of the patients. Huma et al. [21] observed serum electrolyte imbalance in the form of low sodium levels in 52% of patients, low potassium levels in 16% of patients, and low chloride levels in 24% of patients.
It has been demonstrated that laboratory investigations showed electrolyte imbalance and renal impairment in several patients, likely secondary to dehydration from fluid losses and poor oral intake during severe acute illness [4].
The current study recorded that the etiological factors of erythrodermic patients according to both clinical and histopathological evaluations were preexisting dermatoses, malignancies, and drug reactions. The preexisting dermatoses were psoriasis, eczema, pityriasis rubra pilaris, and pemphigus foliaceous. The most common drugs implicated in erythroderma were captopril, diclofenac, and anticonvulsants. Several previous studies have reported that preexisting dermatoses were the main causes of erythroderma [2],[12],[32],[33].
In this study, the main preexisting skin disease of erythrodermic patients was psoriasis. Several studies showed similar results [4],[6],[9],[11],[12],[34]. It has been reported that erythroderma occurs more frequently in patients with long-standing psoriasis [10],[35]. In contrast to the current study, it has been reported that endogenous eczema was the most common cause of erythroderma and followed by psoriasis [7].
This study found that there was moderate and perfect interrater reliability agreement between clinical and histopathological evaluations in the diagnosis of different etiological causes of erythroderma. In contrast to this finding, Hulmani et al. [9], Rym et al. [10], Kondo et al [36], and Bandyaopadhyay et al. [16] found that histopathology was correlated and confirmed the etiology of erythroderma in 80, 74, 72.54, and 52% of the patients, respectively.
The diagnosis of psoriasis as the etiology of erythroderma is more prospered than other etiologies. Numerous clinical studies reported similar findings [6],[9],[11].
This study recommended that multicenter studies on erythroderma with a large sample size are required for more information on the clinical features, etiological factors, diagnosis, treatment, follow-up, and prognosis of the erythroderma.
ConclusionThis study concluded that the main causes of erythroderma were preexisting dermatoses followed by malignancies and drug reactions. Psoriasis was the main preexisting dermatoses in erythrodermic patients. Clinical and histopathology evaluations are essential for accurate diagnosis of different etiological causes of erythroderma.
Acknowledgements
The authors are grateful to all of the faculty and postgraduates in our scientific departments for their invaluable help in conducting this study.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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