CASE REPORT

ERYTHRODERMA ET CAUSA PSORIASIS VULGARIS

Ramona Utami1, Fitriyani Sennang1, Dirmawati Kadir1, Ni Ketut Sungowati2
1
Department of Dermatovenereology Medical Faculty of Hasanuddin University / Wahidin
Sudirohusodo Hospital Makassar
2
Department of Phatology Anatomy Medical Faculty of Hasanuddin University / Wahidin
Sudirohusodo Hospital Makassar

ABSTRACT
Erythroderma is a skin disorder characterized by erythematous
and squama which covers most of the body (more than 90% body
surface area). Erythroderma called exfoliative dermatitis. Erythroderma
is most often caused by spongiotic dermatitis, drug hypersensitivity
reactions, cutaneous lymphoma cells, and other unknown causes
(idiopathic). One case of erythroderma caused the extent of psoriasis
vulgaris was reported with systemic corticosteroids and topical
corticosteroids plus emollient that provides clinical improvement.

Keyword : erythroderma, psoriasis vulgaris

Address for correspondence : Ramona Utami, dr., Department of Dermatovenereology Medical Faculty of Hasanuddin University / Wahidin
Sudirohusodo Hospital Makassar, Blok N/134 Perdos Unhas Tamalanrea Jl. Perintis Kemerdekaan X Makassar, South Sulawesi, Indonesia
90245, ramonautami@gmail.com

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Ramona Utami
INTRODUCTION
Erythroderma is a skin disorder charac-
terized by erythematous and squama
which covers most of the body (more than
90% body surface area). Also called
dermatitis exfoliative erythroderma. (1)
Erythroderma can be caused by a wide
variety of skin and systemic diseases. Of
18 published studies obtained results that
skin disease that affects approximately
plays 52% of cases of erythroderma
include psoriasis (23%), spongiotic
dermatitis (20%), drug hypersensitivity
reactions (15%), CTCL (cutaneous T-cell
lymphoma) or Sezary syndrome 5%, 4%
and seborrheic dermatitis idiopathic 7-
33%.(2) There is no precise data on the
prevalence or incidence of erythroderma.(1)
A study estimating the incidence of
erythroderma was 0.9 per 100,000
population.(2) The incidence of
erythroderma is more common among
men than women, with a ratio of 2:1 - 4:1
and the average age ranged from 41- 61
years. (1,2)
Pathogenesis is still unclear.
However, there are known interactions of
cytokines and cellular adhesion molecules,
including interleukin -1 , -2 and -8,
intercelluler adhesion molecule (ICAM-1)
and tumor necrosis factor (TNF).
Interaction that causes an increase in
epidermal turnover subsequently lead to
an increase in mitotic activity and the
number of cells in the skin
(3,4)
germinativum. Psoriasis is a chronic
skin disease with recurrent lesions typical
form of patches demarcated erythema,
covered by thick layers skuama shiny
white. (5) The cause of psoriasis has not
been clear until now, thought to many
factors that play a role in psoriasis, among
others , genetic factors, environmental,
trauma, infections, drugs, sunlight,
metabolic, psychological, alcohol, smoking
45
erythroderma et causa psoriasis vulgaris
and human immunodeficiency virus (HIV).
(5,6,7)
Diagnosis is based on history,
physical examination and investigations
such as histopathology. Erythroderma
manage-ment in general is based on the
etiology of erythroderma itself. (1-4)
Erythroderma can be a serious medical
cases and require hospitalization. (3,4,6)
Initial treatment in the form of nutrition,
correction of fluid and electrolyte
imbalance, hypothermia prevention and
treatment of secondary infections. (1-4)
Systemic corticosteroids may be
considered in cases of erythrodermic and
generalized pustular psoriasis.(2)
This paper reported a case of
erythroderma caused by psoriasis vulgaris
in men aged 46 years old, treated with
systemic and topical corticosteroids and
emollients and provide a clinically
meaningful change.
CASE REPORT
A man aged 46 years old, admitted
to Dermatology clinic Wahidin
Sudirohusodo Hospital with a complaint of
skin redness and peeling on the face and
almost the entire body approximately 1
month ago. Patients initially complained of
reddish spots appeared on the back and
arms, spread on the feet, hands and face
with exfoliation. The complaint with the
pain and piercing in the skin. No history of
previous treatment. Patients having ever
smoked more than 30 years. No
complaints of joint pain. Denied a history
of alcohol consumption, history of similar
complaints previously denied. A history of
drug allergies and food denied, history of
systemic disease and similar illnesses in
the family denied. On physical
examination found a good general
condition. Vital signs showed blood
pressure 120/80 mm Hg, pulse
80x/minute, respiration rate 20x/minute
and body temperature 37oC. ermatological
IJDV Vol.2 No.2 2013

status examination showed in almost the case differential diagnosis with

entire surface of the body (generalized) erythrodermic et causa psoriasis,
found a macular erythematous, fine erythrodermic et causa seborrheic
scales, and xerosis (Fig. 1a-d). Routine dermatitis, erythrodermic et causa atopic
blood laboratory tests, kidney function and dermatitis. To established the diagnosis
liver function within normal limits. Based skin histopathology examination was
on history and physical examination, this done.

46
Ramona Utami
Management of this patient got systemic
therapy oral methylprednisolone 12 mg
twice a day in morning and afternoon,
erythromycin 500 mg three times a day.
B1, B6 and B12 vitamins were given once
a day. Topical therapy 2.5% hydrocor-
tisone cream (applied on face), clobetasol
propionate cream plus lanolin 10% plus
vaseline smeared onto the upper half of
the body in the morning and half lower
body in the afternoon.
Histopathologic examination
showed a picture of the epidermis with
psoriasiform hyperplasia, mild spongiosis,
hyperkeratosis, focal parakeratosis, focal
hypogranulosis, suprapapilary plate
thinning, there are 1-2 neutrophils in the
area parakeratosis, dilated blood vessels
papillary dermis contains erythrocytes and
there perivasculer lymphocytic inflam-
mation infiltrates. The conclusion was
erythrodermic et causa psoriasis vulgaris
(Fig. 2a and b) On the control day 7,
patient complaints of itching and burning
sensation. Dermatologic examination
showed redness was reduced and
squama thinning. Treatment
methylprednisolone 8 mg dose twice a
day, cetirizine 10 mg once a day at night.
Topical therapy given lanolin 10%, salicylic
acid 3% plus desoximethasone plus
vaseline on the body (except the face and
neck) in the morning and afternoon.
DISCUSSION
This case established the diagnosis
of erythroderma based on history, physical
examination and histopathological
examination. (2) In the history and physical
examination were obtained erythematous
and squama on almost the entire body.
Literature said that symptoms of
erythroderma such as erythema and
squama on the whole body or most of the
body. (1,2,4,6,8,9) Erythroderma can be
caused by skin and systemic diseases. (2)
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erythroderma et causa psoriasis vulgaris
Erythroderma due to the expansion of the
skin disease most often caused by
psoriasis and seborrheic dermatitis. (1,2) In
this case erythroderma caused by
psoriasis vulgaris. Erythroderma is a
disease that is relatively common in
tropical countries. The incidence of
erythroderma is more common among
men than women, with a ratio of 2:1-4:1
and the average age ranged from 41-61
years. (1,2) The patient was a 46 years old
male.
Psoriasis is a chronic inflammatory
skin diseases with recurrent lesions typical
form of patches demarcated erythema,
covered by thick layers squama white
shiny like mica, with candles droplet
phenomenon, koebner phenomenon and
Auspitz signs . (1,2,5,6,9-12) According to
Henseler and Christopers, there are two
forms of the type I psoriasis with onset
before age 40 years and is associated with
human leucocyte antigen (HLA), and type
II with onset after the age of 40 years and
little relation to HLA. (2,6) Our case patient
aged 46 years old and no history of similar
illness in the family. Based on
histopathological exa-mination obtained a
description of the epidermis with
psoriasiform hyperplasia, mild spongiosis,
hyperkeratosis, focal parakeratosis, focal
hipogranulosis, suprapapilary plate
thinning, there are 1-2 neutrophils in the
area parakeratosis, dilated blood vessels
papillary dermis contains erythrocytes and
there perivascular lymphocytic
inflammation infiltrates. The conclusion is
erythrodermic et causa psoriasis vulgaris
can be considered. In the literature
mentioned histopathological picture of
psoriasis vulgaris varies, depending on the
stage of the lesion. Histopathological
picture in this case including the early-
stage lesions. (12)
IJDV
Primary management of erythroderma,
whatever the cause, is water and
electrolyte correction. (1-3,6,9,12) Local skin
care gently, including the use of oatmeal
baths and wet dressings to crusting lesion,
emollients and corticosteroids should be
given. Symptomatic therapies include
antihistamines sedatives for pruritus. (1,2)
Systemic antibiotics required for patients
with systemic secondary infections.
Patients in the absence of secondary
infection may also require systemic
antibiotic therapy as the colonization of
bacteria which can cause exacerbation of
erythroderma. Appropriate literature, the
patient treated with oral antibiotics,
cetirizine (anti-histamine), topical
corticosteroids, emollients (lanolin and
petroleum jelly) which serves to hold the
water evaporation from the skin. (1,2,7,11)
Patient was treated with 4 mg of
methylprednisolone given a starting dose
of 24 mg / day and tappering off in
accordance with the development of
lesions. On the published literature, it is
said that the administration of systemic
corticosteroids provide rapid healing of
psoriasis lesions, but can also make a
flare of psoriasis lesions or turn into
psoriasis pustulosis if its use is stopped
abruptly. (1,2,9)
Patient also got a topical treatment
clobetasol propionate cream added
lanolin 10% and vaseline applied onto the
upper half of the body in the morning and
lower body half in the afternoon. On the
control day 7, redness and squama
reduced. Topical therapy was given
desoximethasone cream added 3%
salicylic acid, 10% lanolin and vaseline
smeared on the body (except the face and
neck) in the morning and afternoon. To
overcome the itch given 1x10 mg cetirizine
tablets at night. (1,2)
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Vol.2 No.2 2013
Prognosis depends on the cause.
Erythroderma prevention can be done by
avoiding the administration of drugs that
can lead to erythroderma. Medical records
of patients known to have allergies, as well
as the discontinuation of systemic steroids
in patients with psoriasis and preventing
rebound flare. (2)
After the lesion got clinical
improvement , the patient should be given
the understanding of the basic causes of
erythroderma disease. (1) It is also clear
that psoriasis is a chronic disease is
genetic, and can not promise complete
recovery and should refrain from any
trigger psoriasis. (1,2,6,13-15)
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