From the Guidelines
The management of erythroderma should prioritize systemic therapy with oral cyclosporine at a dose of 3 to 5 mg/kg/d, due to its rapid onset of action, especially in systemically ill patients. This approach is based on the guidelines of care for the management of psoriasis and psoriatic arthritis, which emphasize the importance of treating erythrodermic psoriasis with systemic therapies that act quickly and have predictable responses 1. The treatment of erythrodermic psoriasis requires a distinct approach from other forms of the disease, and systemic symptoms such as chills, night sweats, and generalized arthralgias along with pedal edema should be considered when making treatment decisions.
Key Considerations
- Topical treatments, including mid-potency topical corticosteroids and emollients, may be helpful for patient comfort and restoration of the normal barrier function of the skin, but are not sufficient as monotherapy for erythrodermic psoriasis.
- Systemic therapy should be based on short-term efficacy rather than long-term results or potential side effects, with the goal of improving the patient's acute illness.
- Other systemic options for erythrodermic psoriasis include acitretin, methotrexate (MTX), and tumor necrosis factor-alpha (TNF-alfa) inhibitors, but these may have limitations such as slow onset of action or potential toxicity.
Treatment Options
- Oral cyclosporine: 3 to 5 mg/kg/d, with careful monitoring for toxicity, especially in patients at higher risk such as the elderly, those with renal disease or hypertension, or those on medications that influence cyclosporine levels.
- Acitretin: may be used in erythrodermic psoriasis, but its slow onset of action and teratogenicity limit its use in certain patients.
- MTX: may be a reasonable choice, especially when given subcutaneously, but requires careful monitoring for hepatic and renal toxicity, and may have effects on spermatogenesis.
- TNF-alfa inhibitors: may be used in erythrodermic psoriasis, but their use should be based on individual patient needs and potential benefits and risks.
Supportive Care
- Hospitalization for fluid and electrolyte replacement, temperature regulation, and nutritional support may be necessary in severe cases.
- Antihistamines such as hydroxyzine may be used to manage pruritus.
- Antibiotics should be administered if secondary infection is present, with careful selection of antibiotics based on potential side effects and interactions with other medications.
From the FDA Drug Label
4 Dermatologic Diseases Pemphigus Bullous dermatitis herpetiformis Severe erythema multiforme (Stevens-Johnson syndrome) Exfoliative dermatitis Mycosis fungoides Severe psoriasis Severe seborrheic dermatitis
The management of Erythroderma may involve the use of prednisone (PO), as it is indicated for Exfoliative dermatitis, which is a condition related to erythroderma.
- Key points:
- Prednisone (PO) is indicated for Dermatologic Diseases, including Exfoliative dermatitis.
- Erythroderma is related to Exfoliative dermatitis.
- The use of prednisone (PO) for Erythroderma management is based on its indication for Exfoliative dermatitis 2.
From the Research
Management of Erythroderma
The management of erythroderma involves a comprehensive approach, including:
- Nutrition expert evaluation
- Fluid imbalance assessment
- Maintaining skin barrier function
- Sedative antihistamines
- Exclusion of secondary bacterial infection 3
Diagnostic Approach
The diagnostic approach to erythroderma must include:
Treatment Modalities
Treatment modalities for erythroderma depend on the underlying etiology, which can include:
- Psoriasis
- Eczematous conditions
- Drug-induced reactions
- Pityriasis rubra pilaris
- Cutaneous T-cell lymphomas 3, 4, 5
Common Causes
The most common causes of acquired erythroderma in adults can be grouped under the acronym PALM, which stands for:
- Psoriasis
- Atopic dermatitis
- Lymphoproliferative disorders
- Medications 4
Topical Steroids
Topical steroids, such as clobetasol propionate, can be used in the treatment of various skin diseases, including atopic dermatitis and psoriasis, but their use must be carefully considered due to potential side effects 6