What causes exfoliative dermatitis?

Answer

Within a large series of patients with exfoliative dermatitis, the underlying etiology was preexisting dermatitis (24%), psoriasis (20%), drug eruptions (19%), and cutaneous T-cell lymphoma (8%).^[1]Within the category of preexisting dermatitis, the most common causes were atopic dermatitis (9%), contact dermatitis (6%), seborrheic dermatitis (4%), and chronic actinic dermatitis (3%). Despite investigation, 25% of exfoliative dermatitis is idiopathic in nature. Less common causes include ichthyoses, bullous dermatoses, pityriasis rubra pilaris, Ofuji papuloerythroderma, hypereosinophilic syndrome,^[4]systemic lupus erythematosus.

Among infants, the major causes of exfoliative dermatitis are ichthyoses, immunodeficiencies, psoriasis, and infection (eg, staphylococcal scalded skin syndrome).^[1]

Common and less common causes of exfoliative dermatitis in adults and clinical clues to diagnosis are included in Table 1.^[5]

Table 1. Clinical Clues to Causes of Exfoliative Dermatitis in Adults (Open Table in a new window)

Underlying Disease	History	Examination
Psoriasis (common)	Medical history or family history of psoriasis Withdrawal of corticosteroids, methotrexate, or cyclosporine	Face is spared Nail pitting, translucent yellow-red nailbed discoloration, onycholysis Inflammatory arthritis
Atopic dermatitis (common)	Past medical history or family history of atopy such as eczema, allergic rhinitis, or asthma Severe pruritus Cataracts	Flexural skin most severely affected Lichenification Prurigo nodularis
Drug reactions (common)	Recent history of morbilliform or scarlatiniform exanthem No past history of skin disease Medication history includes one of implicated drugs	Facial edema Purpura in dependent areas
Idiopathic (common)	Elderly men Severe pruritus Chronic and relapsing	Palmoplantar keratoderma Dermatopathic lymphadenopathy
Cutaneous T-cell lymphoma (less common)	Intense pruritus	Reddish-purple hue Painful, fissured keratoderma Alopecia Leonine facies
Pityriasis rubra pilaris (less common)	Exacerbated by sun exposure Cephalocaudal progression	Salmon hue Sharply demarcated islands of sparing ("nappes claires") Waxy keratoderma Perifollicular keratotic papules
Contact and stasis dermatitis with autosensitization (less common)	History of localized rash Distribution of initial lesions Occupational exposures, hobbies Oral medications (systemic contact dermatitis)
Paraneoplastic erythroderma (less common)	History of malignancy or lymphoproliferative disorder	Fine scale Hyperpigmentation Cachexia

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Table 1. Clinical Clues to Causes of Exfoliative Dermatitis in Adults

Table 1. Clinical Clues to Causes of Exfoliative Dermatitis in Adults

Underlying Disease	History	Examination
Psoriasis (common)	Medical history or family history of psoriasis Withdrawal of corticosteroids, methotrexate, or cyclosporine	Face is spared Nail pitting, translucent yellow-red nailbed discoloration, onycholysis Inflammatory arthritis
Atopic dermatitis (common)	Past medical history or family history of atopy such as eczema, allergic rhinitis, or asthma Severe pruritus Cataracts	Flexural skin most severely affected Lichenification Prurigo nodularis
Drug reactions (common)	Recent history of morbilliform or scarlatiniform exanthem No past history of skin disease Medication history includes one of implicated drugs	Facial edema Purpura in dependent areas
Idiopathic (common)	Elderly men Severe pruritus Chronic and relapsing	Palmoplantar keratoderma Dermatopathic lymphadenopathy
Cutaneous T-cell lymphoma (less common)	Intense pruritus	Reddish-purple hue Painful, fissured keratoderma Alopecia Leonine facies
Pityriasis rubra pilaris (less common)	Exacerbated by sun exposure Cephalocaudal progression	Salmon hue Sharply demarcated islands of sparing ("nappes claires") Waxy keratoderma Perifollicular keratotic papules
Contact and stasis dermatitis with autosensitization (less common)	History of localized rash Distribution of initial lesions Occupational exposures, hobbies Oral medications (systemic contact dermatitis)
Paraneoplastic erythroderma (less common)	History of malignancy or lymphoproliferative disorder	Fine scale Hyperpigmentation Cachexia

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Author

David Vearrier, MD, MPH Professor of Emergency Medicine, Department of Emergency Medicine, University of Mississippi Medical Center

David Vearrier, MD, MPH is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Medical Toxicology, American College of Occupational and Environmental Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Barry E Brenner, MD, PhD, FACEP Program Director, Emergency Medicine, Einstein Medical Center Montgomery

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Mark Louden, MD Assistant Professor of Clinical Medicine, Division of Emergency Medicine, Department of Medicine, University of Miami, Leonard M Miller School of Medicine

Mark Louden, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Mark P Eid, MD Founder and Director, Virginia Dermatology and Skin Surgery Center

Mark P Eid, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, Pennsylvania Academy of Dermatology

Disclosure: Nothing to disclose.

Mary V Kaldas, MD Resident Physician in Anatomic Pathology, National Institutes of Health

Disclosure: Nothing to disclose.

Acknowledgements

Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director for Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine