CASE PRESENTATIONRaheef Alatassi

5th Year Medical Student

Dermatology

History

• Ahmad is 50 years old male came to the on call dermatologist with a 3 day history of feeling generally unwell and redness of all skin associated with desquamation scaling. The condition started in his extremities and face and then rapidly spread over her whole body.

• He also complains of swelling of his arms and legs with severe pruritus

• 5 years before he came to the hospital with well circumscribed erythematous plaques with silver scales over the elbows and a scaly scalp.

• He clinically diagnosed with plaque psoriasis and had been treated with topical corticosteroids and moisturizing creams.

• P . M . H : Tension headache, No other chronic illness

• P . S . H : negative

• Drug history : he takes NSAID

• Social history : Patient is married, lives in a Villa, in Riyadh with his wife. Patient originally from Jeddah but moved to Riyadh 10 years ago. He is a Bank Manger. He denies any history of smoking, alcohol use or IV drugs and there is no history of recent travel.

• Blood transfusion : negative .

• Family hx. : There is a family history of psoriasis

• Allergy hx. : no known allergy to food or drugs.

Systemic review• Constitutional– denies fevers or chills; decreased appetite and weight loss .

• Cardiovascular system: denies chest pains, palpitations, syncope, orthopnea, PND, Edema.

• Respiratory system : denies cough and wheezing and shortness of breath .

• Gastrointestinal tract: No nausea, vomiting, constipation or diarrhea.

• HEENT: denies decreased hearing ,blurring, diplopia, irritation, discharge, vision loss, eye pain, photophobia, ear pain or discharge, tinnitus, nasal obstruction or discharge, nosebleeds, sore throat, hoarseness, dysphagia

• Urogenital system : denies incontinence, dysuria, hematuria, urinary frequency

• Nervous system : denies weakness , transient paralysis, paresthesia, seizures, syncope, tremors, vertigo

• Musculoskeletal system : There is arthralgia and joint swelling. NO muscle cramps, muscle weakness or stiffness

• Metabolic and endocrine : denies cold intolerance, heat intolerance, polydipsia, polyphagia, polyuria

Examination

General:

The patient is Obese, oriented man, Not in respiratory distress.

Not cyanosed

Vitals Result

Temperature 38.6C

Pulse 92 bpm

Respiratory Rate 16 breaths per minute

Blood Pressure 120/88 m Hg

Oxygen Saturation%: 97% on RA

Dermal examination

• There is widespread erythema affecting the face, trunk and limbs with thickening of the skin and associated widespread thick Scale .

• Thick scale is present through the scalp with dystrophy of all 20 nails. (onychodystrophy)

• Over the elbows erythematous plaques with overlying thick scale are seen.

• There is also swelling, pain, and rigidity in his knees and elbows

Differential diagnosis

• Based in the history and clinical examination what is the most likely diagnosis?

1. lichen planus.

2. erytherodermic psoriasis.

3. Atopic dermatitis.

4. Erythema multiform.

5. stevens johnson syndrome

1. lichen planus. (small, polygonal, flat topped papules with Wickham’s striae)

2. erytherodermic psoriasis.

3. Atopic dermatitis. (Fine scale in atopic dermatitis) (no history of allergy)

4. Erythema multiform. (Classic targets / iris – triphasic)

5. stevens johnson syndrome (epidermal detachment, >2 mucosal sites involvement, after drug exposure)

Why it’s Erytherodermic psoriasis ???

• Erythema of all skin associated with desquamation scaling

• Classic plaques of psoriasis over his elbows.

• History of scalp scaling.

• Family history of psoriasis.

• Dystrophic nails.

• There is severe pruritus and fever.

ERYTHRODERMA

Presence of erythema and scaling involving

more than 90% of skin surface.

Primary: erythema (often initially on trunk) extends within few days to weeks to involve whole skin surface. Followed by scaling

Secondary: generalisation of a preceding localized skin disease (e.g. psoriasis, atopic eczema)

Causes of Erythroderma

•Psoriasis• Eczema

• Neoplasia

• Infection – scabies/HIV

• Lichen planus

• Sarcoidosis

• Cutaneous T cell lymphoma.

• Drugs ( lithium, BB, NSAID)

Erythroderma – clinical features

• Rapidly extending erythema (may be universal in 12-48 hrs)

• Fever, shivering, malaise- hypo>hyperthermia

• Scale (fine/thick) –after 2-6 days

• Pruritus (90%) + tightness of skin

• Lichenification

• There is also onycholysis of nails

Complications of Erythroderma

• Thermoregulation/Thrombosis

• Haemodynamic- renal perfusion/CHF/pneumonia/oedema

• Infection - cutaneous and respiratory

• Nutrition ( albumin)/nails/nodes

• Metabolic – electrolyte imbalance

Erythroderma- Investigations

• Diagnosis: Biopsy

• Blood cultures if febrile

• CBC – eosinophilia/lymphocytosis

• UE

• Skin swabs

• ECG – if elderly

Erythroderma - Treatment• Admit to hospital (if acute/unwell)

• Bed rest

• Management of fluid balance and temperature

• Review medications (cease non-essential)

• Treat underlying aggravating condition and any infection

• Topical• Emollients, +/- mild/mod topical steroids

• Wet dressings

• Systemic steroids in some (not if ?psoriasis)

• Referrals – Nutrition/Cardiology

Erytheroderma - Treatment

Specific treatment for erytherodermic psoriasis

• Methotrexate

• Cyclosporine

• Oral retinoid

• Biological (infliximab)

MCQ

Which one of the following statements is true about Erytherodrma ?

a) Erythema of part of skin( < 40 % of skin surface) in erytherodermic psoriasis.

b) There is Thick scale in atopic eczema

c) You can give systemic steroids in erytherodermic psoriasis.

d) Infliximab can be used to treat erytherodermic psoriasis.

Key points

• Erythorderma is when almost the entire skin (>90%) becomes red.

• It is a serious and at times life threating dermatological emergencies.

• Management is supportive in addition to treatment of underlying skin disease.

Reference

• 100 cases in Dermatology.

• Medscape

Thank you