Erythroderma (Generalized Exfoliative Dermatitis) Treatment & Management

Updated: Oct 15, 2020
  • Author: Sanusi H Umar, MD, FAAD; Chief Editor: Dirk M Elston, MD  more...
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Medical Care

Patients presenting acutely with exfoliative dermatitis (ED) often require admission for inpatient management because their total body functions (including intake and output) can require monitoring. Hospital admission should be seriously considered in pediatric patients who present with erythroderma and fever because this presentation is a predictor of hypotension and even toxic shock syndrome. The principle of management is to maintain skin moisture, avoid scratching, avoid precipitating factors, apply topical steroids, and treat the underlying cause and complications. Exfoliative dermatitis commonly resists therapy until the underlying disease is treated (eg, phototherapy, systemic medications in psoriasis). Outcome is unpredictable in idiopathic exfoliative dermatitis. [54] The course is marked by multiple exacerbations, and prolonged glucocorticoid therapy often is needed.

Discontinue all unnecessary medications. Carefully monitor and control fluid intake, because patients can dehydrate or go into cardiac failure; monitor body temperature, because patients may become hypothermic.

Apply tap water–wet dressings (made from heavy mesh gauze); change every 2-3 hours. Apply intermediate-strength topical steroids (eg, triamcinolone cream 0.025-0.5%) beneath wet dressings. Suggest a tepid bath (as it may be comforting) once or more daily between dressing changes. Reduce frequency of dressings and gradually introduce emollients between dressing applications as exfoliative dermatitis improves.

Institute systemic antibiotics if signs of secondary infection are observed. Antihistamines help reduce pruritus and provide needed sedation.

Systemic steroids may be helpful in some cases but should be avoided in suspected cases of psoriasis and staphylococcal scalded skin syndrome.

Increased capillary permeability occasionally is severe enough to justify plasma infusion.

Preexisting malnutrition may become more marked and require nutritional intervention in older patients.

Traditionally, topical corticosteroids under moist occlusion and phototherapy have been used to manage psoriatic erythroderma. [55] Five biologic agents have been approved for the treatment of psoriasis in the United States: infliximab, adalimumab, etanercept, ustekinumab, [56] and secukinumab [57] ; however, their high costs are a deterrent. Ustekinumab and secukinumab may be particularly effective in patients with overlapping features of psoriasis and pityriasis rubra pilaris. [58] At least some of these patients have CARD14 mutations. Small-molecule agents are emerging as a lower cost, therapeutic alternative. [59] According to the Medical Board of the National Psoriasis Foundation, cyclosporine [60] and infliximab appear to be the most effective first-line treatments; other more slowly working, but effective therapies, are acitretin and methotrexate. [61] For secondary treatment options, they recommend etanercept and combination therapy. [62]

The treatment of mycosis fungoides is determined by the staging of the disease. For early refractory mycosis fungoides, skin-directed therapies are the first line of treatment and include topical corticosteroids, topical chemotherapy, topical retinoids, phototherapy, and radiotherapy. [63] In aggressive or advanced-stage disease, systemic therapy is applied, including interferon, oral retinoids, [64, 65] histone deacetylase inhibitors, monoclonal antibodies, [66] extracorporeal photopheresis, [67] and single- and multi-agent chemotherapy. In a select patient population with advanced mycosis fungoides, allogeneic stem cell transplantation is beneficial. [68] Although combination therapy for advanced-stage mycosis fungoides is often reported in the literature, Humme et al [69] found that no combination therapy was more effective than monotherapy in their systematic review. Chemotherapy has been found to have only modest efficacy, [70] and biologic agents and histone deacetylase inhibitors have shown better survival rates than multi-agent chemotherapy (2.5 y vs 9 mo, respectively). [59]  Histone deacetylase inhibitors were developed to inhibit the dysregulation of histone deacetylase enzymes that causes epigenetic changes and contributes to cancer development. [71, 72, 73]

Atopic dermatitis, despite being the most common dermatological condition among the causes of erythroderma, has no specific targeted treatment options. [74]  Therapy is based on avoiding allergens, and emollients and topical and systemic immunosuppressants are used with varying efficacy. There are no approved biologics for atopic dermatitis, mainly owing to their toxicity, contradictory outcomes, and high costs. [42] Oral immunotherapy is an emerging, novel therapy for a select patient population.

Appropriate in/outpatient medications are influenced by the underlying etiology of exfoliative dermatitis. For example, prednisone may be contraindicated in exfoliative dermatitis secondary to psoriasis, while retinoids are an excellent choice for this disease. In patients with mycosis fungoides, who receive a differential diagnosis of psoriasis, special attention must be made prior to prescribing tumor necrosis factor-alpha inhibitors, given that they might cause mycosis fungoides to progress. [75]



Consult a dermatologist for all cases of exfoliative dermatitis (ED).



Ensure adequate nutrition with emphasis on protein intake, since exfoliative dermatitis (ED) patients lose a lot of protein through excessive desquamation and show a tendency toward hypoalbuminemia. Alter diet as necessary if ingestion of a certain food group is suspected as the etiology of exfoliative dermatitis.



Patient activity is as tolerated.



Prevention of exfoliative dermatitis (ED) depends on adequate control of underlying etiology. For example, gentle skin care is key to preventing exfoliative dermatitis flare-ups in atopic dermatitis, while specific treatments for psoriasis should be adhered to when it is the underlying cause.


Long-Term Monitoring

Follow patients discharged from the hospital on an outpatient basis for continued management of underlying disease.

Closely follow patients with no discernible underlying disease (idiopathic exfoliative dermatitis [ED]) using multiple serial biopsies to exclude cutaneous T-cell lymphoma. Since low-dose methotrexate has been shown to be efficacious in the management of erythrodermic cutaneous T-cell lymphoma (as reported by Zackheim et al [76] ), some have advocated the use of methotrexate between rebiopsy periods in patients with idiopathic exfoliative dermatitis that is unremitting despite the use of topical steroids. However, this novel approach should be taken with the understanding that cutaneous T-cell lymphoma develops only in a minority of patients with idiopathic exfoliative dermatitis (7%), especially in the subgroup with persistent chronic disease on long-term follow-up care (as reported by Sigurdsson et al [77] ), and that methotrexate is associated with many adverse effects, including toxicities of the liver, lungs, and bone marrow.

In addition to their high cost, the widespread use of biologics has been deterred by fear of an increased risk of new or recurrent malignancies in patients with psoriasis, although no recent evidence supports this claim. [78]  However tumor necrosis factor-alpha inhibitors and monoclonal antibodies can cause the formation of antidrug antibodies (ADAs) that affect the clinical response, with ADAs reported in 0-44.8% of patients. [79]