Erythroderma

exfoliative dermatitis · generalised exfoliative dermatitis · erythrodermic psoriasis

Inflammation of nearly the whole skin surface - a failure of the skin as an organ, with the physiology of a burn.

ADMITBand A

Red flags

Hypothermia or temperature instability - the patient cannot thermoregulate and needs active warming
Tachycardia and hypotension from transcutaneous fluid loss - this is burn physiology, not simple dehydration
Any blistering, mucosal erosion or detachable epidermis - reconsider epidermal necrolysis
Fever with an unwell patient - secondary bacteraemia through a failed skin barrier

Recognise

On light skin

Confluent bright red skin over almost the entire surface with scaling or desquamation, often with oedema, fissuring and lichenification.

On brown and black skin

The defining redness may be entirely absent as a visual finding. Erythroderma in brown and black skin more often looks dark, violaceous, grey or simply uniformly hyperpigmented, and the diagnosis is frequently delayed for exactly this reason. Use the tone-independent signs: the skin feels hot and tight, scaling and desquamation are visible against any background, and the systemic consequences - hypothermia, tachycardia, oedema - are unaffected by pigment. Compare with an unaffected area if any remains.

In any skin tone

Scaling or desquamation across nearly the whole surface
The skin feels hot and tight; the patient complains of cold and shivers
Hypothermia or temperature instability from loss of thermoregulation
Peripheral oedema and tachycardia from fluid and protein loss
Lymphadenopathy is common and usually reactive
Look for clues to the cause: nail pitting or scalp scale for psoriasis, a drug history, a long-standing eczema, or lymphoma

Distribution

Conventionally defined as erythema involving 90% or more of the body surface, though published thresholds vary between 80% and 90%. Do not let the arithmetic decide: a patient at 85% is in the same failed-barrier physiology as one at 95%, and it is the physiology that drives management.

Photographs

Erythroderma in a Black patient. The published caption for this photograph describes diffuse erythema and desquamation - and the erythema is — Erythroderma in a Black patient. **The published caption for this photograph describes diffuse erythema and desquamation - and the erythema is not visible here at all.** What you can see is the dry, finely cracked, scaling surface and the tight sheen of the skin. That is the whole problem with a diagnosis defined by redness over 90% of the body surface: on skin this dark the defining sign cannot be seen, so the diagnosis has to be made on scale, heat loss, shivering, tachycardia and the feel of the skin instead.
Fitzpatrick IV-VI (Fitzpatrick type estimated from the photograph, not stated by the source) · Qasim A, Javed N, Jog AP, Soliman M, Baqui A · Toxic Shock Syndrome Secondary to Erythroderma: Unraveling the Underlying Triggers. Cureus 2023;15 · CC BY

The same patient's hand: the epidermis is lifting away in sheets, leaving pink dermis exposed against dark surrounding skin. That two-tone a — The same patient's hand: **the epidermis is lifting away in sheets, leaving pink dermis exposed against dark surrounding skin.** That two-tone appearance is the one thing that is unmissable on any skin tone. Erythroderma at this stage behaves like a burn - fluid and heat are lost through the skin, and hypothermia, hypoalbuminaemia and high-output cardiac failure are the reasons this is a Band A entry.
Fitzpatrick IV-VI (Fitzpatrick type estimated from the photograph, not stated by the source) · Qasim A, Javed N, Jog AP, Soliman M, Baqui A · Toxic Shock Syndrome Secondary to Erythroderma: Unraveling the Underlying Triggers. Cureus 2023;15 · CC BY

Provenance for every photograph in this library: image licences. How much of the corpus still has no darker-skin photograph: skin tone coverage.

Mimics

Stevens-Johnson syndrome / toxic epidermal necrolysis — Necrolysis also involves most of the surface but detaches epidermis and erodes mucosa; erythroderma scales without shearing
Staphylococcal scalded skin syndrome — In a young child, generalised erythema with desquamation may be SSSS; the mucosa is spared in both, so look for the shearing
DRESS - drug reaction with eosinophilia and systemic symptoms — DRESS can become erythrodermic; the eosinophilia and organ involvement identify it
Toxic shock syndrome — Both give generalised erythema with later desquamation; TSS is shocked from the outset

What to do in the ED

Treat the physiology first: warm the patient actively, measure a core temperature, and correct fluid and electrolyte losses
Take FBC, renal and liver function, albumin, CRP, cultures if febrile, and a film if lymphoma is a consideration
Stop any plausible culprit drug
Emollient generously and wrap; avoid potent topical steroids until dermatology has assessed, since the cause determines treatment
Refer to dermatology the same day and admit - this is not a discharge diagnosis at any age
Involve burns or critical care if thermoregulation or haemodynamics are failing

Disposition

ADMIT

Admit with same-day dermatology. Consider burns or critical care input where thermoregulation, fluid balance or the skin barrier has failed.

Sources

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