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Table

Erythroderma: How to Know If It Is Drug Induced?

Exfoliative dermatitis/erythroderma is a generalized
inflammatory disorder of the skin manifesting with erythema
and scaling affecting >90% of the skin surface.[1]    Primary
erythroderma arises on normal‑looking skin due to an
underlying systemic disorder or because of drug reaction, and
secondary erythroderma arises from a preexisting dermatosis.
There is an increase in the rate of epidermal cell turnover, and
transit time of the cells through the epidermis is shortened.
Greater amount of cell components are lost in the form of
scales, estimated to be 20–30 gm/day. Males, aged above 30
years of age, are affected more often. Erythema is initially
localized, scaling usually accompanies or follows erythema.
Scales may be fine or large.[2] Large scales are seen in acute
cases and small ones in chronic cases [Figures 1 and 2].
Table 1 enlists differences between the two so as to help
physicians differentiate between the two. Diffuse and fine
scaling is usually seen in non-drug induced erythroderma
[Figure 2]. Patient complains of pruritus and irritation, more

Figure 1: Scaly plaques in a patient of drug-induced erythroderma (picture

Courtesy Dr. Yashpal Manchanda, Senior Consultant, AL farwaaniya Figure 2: Diffuse fine scaling and erythema in a patient of psoriatic
hospital, Kuwait) erythroderma

Table 1: Differentiating features between Non drug‑induced erythroderma and drug‑induced erythroderma
Non drug‑induced erythroderma Drug‑induced erythroderma
Onset Insidious Acute or subacute
Progression Gradual Rapid
Clinical features In the initial stages, morphology is that of disease It usually starts with pruritic maculopapular rash or lichenoid
responsible for causing erythroderma. In later or urticarial rash which evolves into erythroderma. Scales are
stages, there is diffuse scaling and erythema usually large, especially during acute phase
Resolution Slow to subside Faster (after drug discontinuation)
Causative factors Extensive or unstable psoriasis, eczema, Many drugs can cause erythroderma. In clinical practice, drugs
infections, GVHD, immunobullous disorder, and such as dapsone, phenytoin, AKT, antibacterial, beta-blockers
malignancy are likely causes. In clinical practice, carbamazepine, proton-pump inhibitor, and phenylbutazone
the most common cause is psoriatic erythroderma can cause erythroderma[3]
Sites involved Skin Skin. Mucous membranes may also be involved
Temperature Present Fever mostly present (associated)
Nail changes, arthritis, Seen Not seen
palmoplantar keratoderma
Lymphadenopathy Present Present
Relapse Seen No relapse
Hospitalization time Long duration stay Short duration stay
Skin and lymph node biopsy Presents with changes of preexisting dermatosis Histology is like pseudolymphoma. Changes suggestive of a
drug reaction such as necrosis of epidermis and dense dermal
infiltrate of lymphocytes with/without eosinophils
Systemic involvement Usually secondary to the erythroderma Deranged liver function test and leukocytosis with
predominant eosinophilia (AEC> 1000) can be seen in DRESS
GVHD: Graft versus host disease, AEC: Absolute eosinophil count, DRESS: Drug reaction, eosinophilia and systemic symptoms, AKT: Antitubercular drugs

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Das and Sharma: Table: Drug induced erythroderma
common is feeling of tightness. Apart from these, patient may
experience shivering or fever due to temperature dysregulation.
Nail changes and lymphadenopathy along with ascites and
hepatomegaly can also be seen. Laboratory findings include
anemia, hypoproteinemia, raised erythrocyte sedimentation
rate, eosinophilia, atypical lymphocytosis. Although it is
not easy to pinpoint the etiology, it is very important to
differentiate drug induced erythroderma from non drug induced
erythroderma. A thorough assessment of signs and symptoms,
meticulous history taking and laboratory findings along with
histopathology can help in the correct management of patients
of erythroderma.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Sudip Das, Nidhi Sharma
Department of Dermatology, Calcutta National
Medical College, Kolkata,
West Bengal, India
Address for correspondence: Dr. Sudip Das,
Department of Dermatology, Calcutta National Medical College,
Kolkata, West Bengal, India
E‑mail: sudipderma@gmail.com
Indian Journal of Drugs in Dermatology ¦ Volume 3 ¦ Issue 2 ¦ July‑December 2017
References
1. César A, Cruz  M, Mota A, Azevedo  F. Erythroderma. A  clinical and
etiological study of 103 patients. J Dermatol Case Rep 2016;10:1‑9.
2. Hulmani  M, Nandakishore  B, Bhat  MR, Sukumar  D, Martis  J,
Kamath  G, et al. Clinico‑etiological study of 30 erythroderma
cases from tertiary center in South India. Indian Dermatol Online J
2014;5:25‑9.
3. Yacoub  MR, Berti  A, Campochiaro  C, Tombetti  E, Ramirez  GA,
Nico A, et al. Drug induced exfoliative dermatitis: State of the art. Clin
Mol Allergy 2016;14:9.
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