Psoriatic erythroderma

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Psoriatic erythroderma
Other namesErythrodermic psoriasis or Von Zumbusch Psoriasis
SpecialtyDermatology Edit this on Wikidata

Psoriatic erythroderma represents a form of psoriasis that affects all body sites, including the face, hands, feet, nails, trunk, and extremities.[1]: 410–411 [2]: 195  This specific form of psoriasis affects 3 percent of persons diagnosed with psoriasis.[3] First-line treatments for psoriatic erythroderma include immunosuppressive medications such as methotrexate, acitretin, or ciclosporin.[4]

Signs and symptoms[edit]

Psoriatic erythroderma displays generalized cutaneous symptoms, including scaling, hair loss, erythema, edema, pruritus, diffuse desquamation, and occasionally exudative lesions and palmoplantar or diffuse psoriatic plaques.[5][6] Psoriatic erythroderma frequently results in changes to the nails, which can vary from minor pitting to severe onychodystrophy and typically affect the fingernails rather than the toenails.[7][8] Systemic symptoms may also include fever, tachycardia, chills, exhaustion, malaise, lymphadenopathy, myalgia, arthralgia, insomnia, diarrhea, sweats, constipation, changes in weight, allodynia, and, in rare cases, high output heart failure (caused by excessive edema and water loss) and cachexia.[9][10][11]

Causes[edit]

Psoriatic erythroderma can be congenital or secondary to an environmental trigger.[12][13][14] Environmental triggers that have been documented include sunburn, skin trauma, psychological stress, systemic illness, alcoholism, drug exposure, chemical exposure (e.g., topical tar, computed tomography contrast material), and the sudden cessation of medication.[15][16][10] Methotrexate, efalizumab, and topical and oral steroids are common antipsoriatic drugs that can cause the rebound phenomenon.[17][10][18] Leukemia, T-cell lymphoma, gout, and the human immunodeficiency virus are among the systemic diseases that have been linked to psoriatic erythroderma.[19][20] Pharmaceutical drugs such as etretinate, acitretin, infliximab, antimalarials, lithium, and trimethoprim/sulfamethoxazole have also been documented in the literature to cause psoriatic erythroderma.[8][21][22]

Diagnosis[edit]

Many authors propose that generalized inflammatory erythema involving at least 75% of the body's surface area, with or without exfoliation, is necessary for a clinical diagnosis of psoriatic erythroderma.[23] According to some authors, the affected area of the body must be at least 90% of its surface.[10][9][5]

Histologic analysis of psoriatic erythroderma, which shows dilated capillaries, an epidermal perivascular infiltrate of eosinophils and lymphocytes, and hyperkeratosis, can confirm the diagnosis if clinical suspicion is high.[23] Some characteristics of classical psoriasis, such as parakeratosis, acanthosis,, Munro micro-abscesses, spongiosis, and sporadic apoptotic keratinocytes, are additional histological features of psoriatic erythroderma.[24][15][25]

Treatment[edit]

Correcting any abnormalities in fluid, protein, or electrolyte levels; evaluating nutrition; guarding against hypothermia; and treating any secondary infections are all important aspects of the initial management of psoriatic erythroderma.[23]

The literature has documented the use of topical emollients, topical vitamin D analogs, colloidal oatmeal baths, medium potency topical steroids under occlusive dressings, and various combinations of the aforementioned.[23]

For moderate-to-severe plaque psoriasis, phototherapy is an efficient first-line treatment that reduces inflammation by promoting keratinocyte apoptosis, suppressing keratinocyte proliferation, and reducing the activity of the Th1 and Th17 inflammatory pathways.[26] Given the risk of koebernization, phototherapy is not recommended in cases of acute, fulminant psoriatic erythroderma.[15] However, once the course of the disease becomes more stable, phototherapy may be useful in the long-term management of psoriatic erythroderma.[9]

For moderate-to-severe psoriasis and other hyperkeratotic disorders, retinoids, including acitretin, are useful systemic treatments.[23]

Dihydrofolate reductase is inhibited by the immunosuppressive medication methotrexate. For individuals with plaque psoriasis whose condition cannot be adequately controlled with topicals alone, oral systemic therapy combined with methotrexate is the first choice.[23]

Cyclosporine is an immunosuppressive medication that inhibits the transcription of IL-2, which hinders T-cell proliferation and function.[23] The US Food and Drug Administration has approved cyclosporine for the management of severe plaque psoriasis in immunocompetent individuals.[27] Cyclosporine is regarded as an essential first-line medication for the management of unstable cases of psoriatic erythroderma because of its quick onset of action.[23]

Another immune suppressant that specifically blocks activated lymphocytes is mycophenolate mofetil. A randomized controlled trial, small clinical studies, and multiple case reports have demonstrated its effectiveness as a monotherapy for moderate-to-severe psoriasis.[28][29]

A new class of medications known as biologic therapy targets particular immune system cytokines. These drugs show great promise as a substitute for traditional immunosuppressants like cyclosporine and methotrexate because of their improved selectivity. A few types of biologics, such as TNF-α inhibitors, IL-12/IL-23 inhibitors, and most recently, IL-17A inhibitors, have been used to treat psoriatic erythroderma.[23]

See also[edit]

References[edit]

  1. ^ Freedberg, et al. (2003). Fitzpatrick's Dermatology in General Medicine. (6th ed.). McGraw-Hill. ISBN 0-07-138076-0.
  2. ^ James, William; Berger, Timothy; Elston, Dirk (2005). Andrews' Diseases of the Skin: Clinical Dermatology. (10th ed.). Saunders. ISBN 0-7216-2921-0.
  3. ^ "Psoriasis types: Erythrodermic | National Psoriasis Foundation". www.psoriasis.org. Retrieved 2019-10-25.
  4. ^ Zattra E, Belloni Fortina A, Peserico A, Alaibac M (May 2012). "Erythroderma in the era of biological therapies". Eur J Dermatol. 22 (2): 167–71. doi:10.1684/ejd.2011.1569. PMID 22321651.
  5. ^ a b Viguier, M.; Pagès, C.; Aubin, F.; Delaporte, E.; Descamps, V.; Lok, C.; Beylot-Barry, M.; Séneschal, J.; Dubertret, L.; Morand, J.-J.; Dréno, B.; Bachelez, H. (June 11, 2012). "Efficacy and safety of biologics in erythrodermic psoriasis: a multicentre, retrospective study". British Journal of Dermatology. 167 (2). Oxford University Press (OUP): 417–423. doi:10.1111/j.1365-2133.2012.10940.x. ISSN 0007-0963. PMID 22413927. S2CID 41576517.
  6. ^ Richetta, Antonio Giovanni; Maiani, Elisa; Carlomagno, Valentina; Carboni, Valentina; Mattozzi, Carlo; Giancristoforo, Simona; Calvieri, Stefano (2009). "Treatment of erythrodermic psoriasis in HCV+ patient with adalimumab". Dermatologic Therapy. 22. Hindawi Limited: S16–S18. doi:10.1111/j.1529-8019.2009.01266.x. ISSN 1396-0296. PMID 19891686.
  7. ^ Boyd, Alan S.; Menter, Alan (1989). "Erythrodermic psoriasis". Journal of the American Academy of Dermatology. 21 (5): 985–991. doi:10.1016/S0190-9622(89)70287-5.
  8. ^ a b Teran, Carlos G; Teran-Escalera, Carlos N; Balderrama, Carola (June 15, 2010). "A severe case of erythrodermic psoriasis associated with advanced nail and joint manifestations: a case report". Journal of Medical Case Reports. 4 (1). Springer Science and Business Media LLC: 179. doi:10.1186/1752-1947-4-179. ISSN 1752-1947. PMC 2893194. PMID 20550707.
  9. ^ a b c Rosenbach, Misha; Hsu, Sylvia; Korman, Neil J.; Lebwohl, Mark G.; Young, Melodie; Bebo, Bruce F.; Van Voorhees, Abby S. (2010). "Treatment of erythrodermic psoriasis: From the medical board of the National Psoriasis Foundation". Journal of the American Academy of Dermatology. 62 (4). Elsevier BV: 655–662. doi:10.1016/j.jaad.2009.05.048. ISSN 0190-9622. PMID 19665821.
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  12. ^ Patil, JayashreeDinkar; Chaudhary, ShyamSundar; Rani, Neha; Mishra, AnupKumar (2014). "Follicular psoriasis causing erythroderma in a child: A rare presentation". Indian Dermatology Online Journal. 5 (1). Medknow: 63–65. doi:10.4103/2229-5178.126036. ISSN 2229-5178. PMC 3937492. PMID 24616860.
  13. ^ Kumar, Parimalam; Thomas, Jayakar; Dineshkumar, Devaraj (2015). "Histology of Psoriatic Erythroderma in Infants: Analytical Study of Eight Cases". Indian Journal of Dermatology. 60 (2). Wolters Kluwer -- Medknow Publications: 213. doi:10.4103/0019-5154.152575 (inactive 2024-02-05). PMC 4372939. PMID 25814735.{{cite journal}}: CS1 maint: DOI inactive as of February 2024 (link)
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  16. ^ Evans, A.V.; Parker, J.C.; Russell-Jones, R. (2002). "Erythrodermic psoriasis precipitated by radiologic contrast media∗". Journal of the American Academy of Dermatology. 46 (6). Elsevier BV: 960–961. doi:10.1067/mjd.2002.120570. ISSN 0190-9622. PMID 12063501.
  17. ^ Chiricozzi, Andrea; Saraceno, Rosita; Cannizzaro, Maria Vittoria; Nisticò, Steven P.; Chimenti, Sergio; Giunta, Alessandro (2012). "Complete Resolution of Erythrodermic Psoriasis in an HIV and HCV Patient Unresponsive to Antipsoriatic Treatments after Highly Active Antiretroviral Therapy (Ritonavir, Atazanavir, Emtricitabine, Tenofovir)". Dermatology. 225 (4). S. Karger AG: 333–337. doi:10.1159/000345762. hdl:11568/777636. ISSN 1018-8665. PMID 23295963.
  18. ^ WANG, Ting-Shun; TSAI, Tsen-Fang (May 4, 2011). "Clinical experience of ustekinumab in the treatment of erythrodermic psoriasis: A case series". The Journal of Dermatology. 38 (11). Wiley: 1096–1099. doi:10.1111/j.1346-8138.2011.01224.x. ISSN 0385-2407. PMID 21545503. S2CID 46177144.
  19. ^ Strober, Bruce E.; Clay Cather, Jennifer; Cohen, David; Crowley, Jeffrey J.; Gordon, Kenneth B.; Gottlieb, Alice B.; Kavanaugh, Arthur F.; Korman, Neil J.; Krueger, Gerald G.; Leonardi, Craig L.; Schwartzman, Sergio; Sobell, Jeffrey M.; Solomon, Gary E.; Young, Melodie (March 30, 2012). "A Delphi Consensus Approach to Challenging Case Scenarios in Moderate-to-Severe Psoriasis: Part 2". Dermatology and Therapy. 2 (1). Springer Science and Business Media LLC: 2. doi:10.1007/s13555-012-0002-x. ISSN 2193-8210. PMC 3510406. PMID 23205325.
  20. ^ Liu, Mei; Li, Jiu-Hong; Li, Bo; He, Chun-Di; Xiao, Ting; Chen, Hong-Duo (2009). "Coexisting gout, erythrodermic psoriasis and psoriatic arthritis". European Journal of Dermatology. 19 (2). John Libbey Eurotext: 184–185. doi:10.1684/ejd.2008.0607. ISSN 1167-1122. PMID 19106055.
  21. ^ Bruzzese, V.; Pepe, J. (2009). "Efficacy of Cyclosporine in the Treatment of a Case of Infliximab-Induced Erythrodermic Psoriasis". International Journal of Immunopathology and Pharmacology. 22 (1). SAGE Publications: 235–238. doi:10.1177/039463200902200126. ISSN 2058-7384. PMID 19309571. S2CID 22377812.
  22. ^ BS, Jennifer Ahdout; MD, Hilary Mandel; MD, Melvin Chiu (January 16, 2024). "Erythroderma in a Patient Taking Acitretin for Plaque Psoriasis". JDDonline — Journal of Drugs in Dermatology. Retrieved February 5, 2024.
  23. ^ a b c d e f g h i Liao, Wilson; Singh, Rasnik; Lee, Kristina; ucmak, derya; Brodsky, Merrick; Atanelov, Zaza; Farahnik, Benjamin; Abrouk, Michael; Nakamura, Mio; Hao Zhu, Tian (2016). "Erythrodermic psoriasis: pathophysiology and current treatment perspectives". Psoriasis: Targets and Therapy. 6. Informa UK Limited: 93–104. doi:10.2147/ptt.s101232. ISSN 2230-326X. PMC 5572467. PMID 28856115.
  24. ^ Wang, Lifeng; Gu, Yunhe; Zhang, Feng; Li, Heyu; Zhou, Yicheng (2014). "Caveolin-1 expression in different types of psoriatic lesions: Analysis of 66 cases". Indian Journal of Dermatology. 59 (3). Medknow: 225–229. doi:10.4103/0019-5154.131374. ISSN 0019-5154. PMC 4037939. PMID 24891649.
  25. ^ Cox, N.H.; Gordon, P.M.; Dodd, H. (2002). "Generalized pustular and erythrodermic psoriasis associated with bupropion treatment". British Journal of Dermatology. 146 (6). Oxford University Press (OUP): 1061–1063. doi:10.1046/j.1365-2133.2002.04679.x. ISSN 0007-0963. PMID 12072078. S2CID 45991779.
  26. ^ Racz, Emoke; Prens, Errol P. (2015). "Phototherapy and Photochemotherapy for Psoriasis". Dermatologic Clinics. 33 (1). Elsevier BV: 79–89. doi:10.1016/j.det.2014.09.007. ISSN 0733-8635. PMID 25412785.
  27. ^ Marqueling, Ann L.; Cordoro, Kelly M. (2013). "Systemic Treatments for Severe Pediatric Psoriasis". Dermatologic Clinics. 31 (2). Elsevier BV: 267–288. doi:10.1016/j.det.2012.12.005. ISSN 0733-8635. PMID 23557655.
  28. ^ Zhou, Youwen; Rosenthal, Don; Dutz, Jan; Ho, Vincent (July 1, 2003). "Mycophenolate Mofetil (CellCept) for Psoriasis: A Two-Center, Prospective, Open-Label Clinical Trial". Journal of Cutaneous Medicine and Surgery: Incorporating Medical and Surgical Dermatology. 7 (3). SAGE Publications: 193–197. doi:10.1007/s10227-002-0113-6. ISSN 1203-4754. PMID 12704533. S2CID 20733785.
  29. ^ Geilen, C.C.; Arnold, M.; Orfanos, C.E. (2001). "Mycophenolate mofetil as a systemic antipsoriatic agent: positive experience in 11 patients". British Journal of Dermatology. 144 (3). Oxford University Press (OUP): 583–586. doi:10.1046/j.1365-2133.2001.04088.x. ISSN 0007-0963. PMID 11260019. S2CID 8763856.

Further reading[edit]

External links[edit]

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