If after 4days there is not an improvement it is advised to consider the association of steroid or its replacement with one of the following drugs [49, 93]: Intravenous immunoglobulins (IVIG): play their role through the inhibition of FasFas ligand interaction that it is supposed to be the first step in keratinocytes apoptosis [33]. 2011;128(6):126676. Adverse cutaneous drug reaction. Br J Dermatol. McCormack M, et al. The fluid of blisters from TEN patients was found to be rich in TNF-, produced by monocytes/macrophages present in the epidermis [42], especially the subpopulation expressing CD16, known to produce higher levels of inflammatory cytokines [43]. All non-indispensable drugs have to be stopped because they could alter the metabolism of the culprit agent. Although the final result of this dual interaction is still under investigation, it seems that the combination of TNF-, IFN- (also present in TEN patients) and the activation of other death receptors such as TWEAK can lead to apoptosis of keratinocytes [44]. The erythrodermic form of mycosis fungoides and the Szary syndrome may also be difficult to distinguish from benign erythroderma. StevensJohnson syndrome and toxic epidermal necrolysis: a review of the literature. Fas-FasL interaction: Fas is a membrane-bound protein that after interaction with Fas-ligand (FasL) induces a programmed cell death, through the activation of intracellular caspases. 2012;42(2):24854. The applications of topical cyclosporine and autologous serum have also been showed to be useful in refractory cases [103]. 2010;85(2):1318. In most severe cases the suggested dosage is iv 11.5mg/kg/day. PubMedGoogle Scholar. 2005;136(3):20516. The overall mortality rate is roughly 30%, ranging from 10% for SJS to more than 30% for TEN, with the survival rate worsening until 1year after disease onset [9, 1821]. 1995;333(24):16007. Exfoliative dermatitis accounts for about 1 percent of all hospital admissions for dermatologic conditions.3, Although the disease affects both men and women, it is more common in men, with an average male-to-female ratio of 2.3:1. Mortality rate of patients with TEN has shown to be directly correlated to SCORTEN. Several authors report the incidence of hospitalization for EM ranging from 0.46 cases per million people per year of northern Europe [11] to almost 40 cases per million people per year of United States [12]. CAS Takahashi R, et al. Copyright 1999 by the American Academy of Family Physicians. Infliximab was used in cases refractory to high-dosage steroid therapy and/or IVIG. Hospitalization and dermatologic consultation are indicated in most cases to ensure that all of the necessary cutaneous, laboratory and radiologic investigations and monitoring are performed. 2013;69(2):1734. AR 40-501 14 June 2017 33 e. Dermatitis herpetiformis. Tohyama M, et al. In: Eisen AZ, Wolff K, editors. SSSS is characterized by periorificial face scabs, de-epithelialization of friction zones and conspicuous desquamation after initial erythroderma. Roujeau JC, et al. Linear IgA dermatosis most commonly presents in patients older than 30years. Still, treatment indication, choice and dosage remain unclear, and efficacy yet unproven. Fernando SL. PMC After 24 hours, split formation was evident in hematoxylin and eosin-stained sections of HOSCs treated . The syndrome has been described previously in association with phenindione administration, leptospirosis and heavy metal poisoning. Mona-Rita Yacoub. The long-term prognosis is good in patients with drug-induced disease, although the course tends to be remitting and relapsing in idiopathic cases. Synthetic bilaminar membranes with silver nitrate have also a role in skin repairing and avoid protein loss through the damaged skin [100, 101]. A severity-of-Illness score for toxic epidermal necrolysis (SCORTEN) has been proposed and validated to predict the risk of death at admission [81]. These molecules may play a role in amplifying the immune response and in increasing the release of other toxic metabolites from inflammatory cells [48]. 2012;51(8):889902. J Burn Care Res. Since cutaneous function as a multiprotective barrier is so disrupted in exfoliative dermatitis, the body loses heat, water, protein and electrolytes, and renders itself much more vulnerable to infection. Chung W-H, et al. Herpes simplex virus (HSV) 1 and 2 are the main triggers in young adults (>80% of cases), followed by Epstein-Barr virus (EBV), and Mycoplasma pneumonia [5558]. Med., 1976, 6, pp. New York: McGraw-Hill; 2003. p. 54357. Avoid rubbing and scratching. A pseudolymphoma reaction with fever, arthralgias, lymphadenopathy, hepatosplenomegaly, anemia and erythroderma may develop as a result of hypersensitivity to dapsone or antiepileptic drugs. J Immunol. Gastric protection. The efficacy of intravenous immunoglobulin for the treatment of toxic epidermal necrolysis: a systematic review and meta-analysis. 2019 Jan 6;59:463-486. doi: 10.1146/annurev-pharmtox-010818-021818. Epidemiological studies on EM, SJS and TEN syndromes report different results, probably related to several biases, such as ethnical differences, diagnostic criteria and drug consumption patterns in different socio-economic systems. Antipyretic therapy. It should be considered only once the patient is stable and if the skin damage is still ongoing and doesnt respond to other conventional therapies (corticosteroids or IVIG). Moreover, after granulysin depletion, they observed an increase in cell viability. Oral manifestations of erythema multiforme. 2023 Jan 30;11(2):346. doi: 10.3390/microorganisms11020346. Among the anti-tubercular drugs exfoliative dermatitis is reported with rifampicin, isoniazid, ethambutol, pyrazinamide, streptomycin, PAS either singly or in combination of two drugs in some cases. Antiepileptic medications, antihypertensive medications, antibiotics, calcium channel blockers and a variety of topical agents (Table 2)2,3,69 can cause exfoliative dermatitis, but theoretically, any drug may cause exfoliative dermatitis. [117] described a cohort of ten patients affected by TEN treated with a single dose of etanercept 50mg sc with a rapid and complete resolution and without adverse events. In the acute phase, before determination of the etiology, treatment consists of measures to soothe the inflamed skin. Ethambutol Induced Exfoliative Dermatitis. Advise of potential risk to a fetus and use of effective contraception. Once ED has occurred, it has to be managed in the adequate setting with a multidisciplinary approach, and every effort has to be made to identify and avoid the trigger and to prevent infectious and non-infectious complications. Allergol Immunopathol (Madr). [71] realized an algorhitm named ALDEN (algorithm of drug causality for epidermal necrolysis) which helps to establish a cause/effect relationship as probable or very probable in 70% of cases. Would you like email updates of new search results? Other patients may warrant PUVA (psoralen plus ultraviolet A) phototherapy, systemic steroids (if psoriasis has been ruled out), retinoids (for exfoliative dermatitis secondary to psoriasis and pityriasis rubra pilaris), or immunosuppressive agents such as methotrexate (Rheumatrex) and azathioprine (Imuran).2527, When used as adjunctive therapy, behavior modification designed to eliminate persistent scratching has been successful in reducing the rate of excoriation and increasing the rate of healing.28. Erythema multiforme (EM), StevensJohnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are the main clinical presentations of drug induced ED. Exp Dermatol. In the 5 studies that concluded negatively for IVIG, the dosage was below 0.4g/kg/day and treatment was maintained for less than 5days. Allergy. 2003;21(1):195205. ALDEN has shown a good accuracy to assess drug causality compared to data obtained by pharmacovigilance method and casecontrol results of the EuroSCAR casecontrol analysis for drugs associated with TEN. Cutaneous drug eruptions are one of the most common types of adverse reaction to medications, with an overall incidence of 23% in hospitalized patients [1]. Neoplastic conditions (renal and gastric carcinoma), autoimmune disease (inflammatory bowel disease), HIV infection, radiation, and food additives/chemicals have been reported to be predisposing factor [59]. Antibiotics: amoxicillin, ampicillin, ciprofloxacin, demeclocycline , doxycycline , minocycline, nalidixic acid, nitrofurantoin, norfloxacin, penicillin , rifampicin, streptomycin, tetracycline , tobramycin, trimethoprim, trimethoprim + sulphamethoxazole, vancomycin Anticonvulsants : barbiturates, carbamazepine Toxic epidermal necrolysis: Part I Introduction, history, classification, clinical features, systemic manifestations, etiology, and immunopathogenesis. and transmitted securely. [Erythema multiforme vs. Stevens-Johnson syndrome and toxic epidermal necrolysis: an important diagnostic distinction]. Genotyping is recommended in specific high-risk ethnic groups (e.g. In SJS and TEN mucosal erosions on the lips, oral cavity, upper airways, conjunctiva, genital tract or ocular level are frequent [60, 6870]. Erythema multiforme. Role of nanocrystalline silver dressings in the management of toxic epidermal necrolysis (TEN) and TEN/StevensJohnson syndrome overlap. In particular, a specific T cell clonotype was present in the majority of patients with carbamazepine-induced SJS/TEN and that this clonotype was absent in all patients tolerant to the drug who shared the same HLA with the SJS/TEN patients [45]. Google Scholar. 1. Br J Dermatol. 2012;27(4):21520. Download Free PDF. Its also characterized by a cell-poor infiltrate, where macrophages and dendrocytes with a strong TNF- immunoreactivity predominate [6, 50]. In this study, 965 patients were reviewed. [3] The causes and their frequencies are as follows: Idiopathic - 30% Drug allergy - 28% Seborrheic dermatitis - 2% Contact dermatitis - 3% Atopic dermatitis - 10% Lymphoma and leukemia - 14% Psoriasis - 8% Treatment [ edit] Huang SH, et al. Clinicians using antivirals for mpox should be alert for drug-drug interactions with any antiretrovirals used to prevent 16, 17 or treat 18 HIV infection as well as with any other medications used to prevent or treat HIV-related opportunistic infections. Erythema multiforme: a review of epidemiology, pathogenesis, clinical features, and treatment. View ABRIGO_Worksheet #8 Drug Study_Endocrine System.pdf from NCM 06 at Southern Luzon State University (multiple campuses). Half-life of the drug is approximately 54 h. Modification of nitisinone in liver and renal dysfunction is yet to be studied. Acute interstitial nephritis associated with hepatitis, exfoliative dermatitis, fever and eosinophilia is uncommon. Tang YH, et al. Article Toxic epidermal necrolysis and StevensJohnson syndrome. In ED increased levels of FasL have been detected in patients sera [33]. Main discriminating factors between EMM, SJS, SJS-TEN, TEN and SSSS is summarized in Table3 [84]. Chan HL, et al. PubMed Albumin is recommended only is albumin serum level is <2.5mg/dL. On the other hand, it has been demonstrated that genetic predisposition may increase the risk for sulphonamide-induced [24] and carbamazepine-induced TEN and SJS [25]. 2. Med Sci Monit. Fritsch PO. Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS): Focus on the Pathophysiological and Diagnostic Role of Viruses. . J Am Acad Dermatol. New York: McGraw-Hill; 2003. pp. Manage cookies/Do not sell my data we use in the preference centre. In vitro diagnostic assays are effective during the acute phase of delayed-type drug hypersensitivity reactions. Wetter DA, Camilleri MJ. Immunoregulatory effector cells in drug-induced toxic epidermal necrolysis. 2011;50(2):2214. Add 1 cup (about 236 milliliters) of vinegar to a bathtub filled with warm water. [81]. Recurrent erythema multiforme: clinical characteristics, etiologic associations, and treatment in a series of 48 patients at Mayo Clinic, 2000 to 2007. In HIV patients, the risk of SJS and TEN have been reported to be thousand-fold higher, roughly 1 per 1000 per year [19]. This site needs JavaScript to work properly. The dermo-epidermal junction and epidermis are infiltrated mostly by CD8+ T lymphocytes whereas dermal infiltrate, mainly made from CD4+ T lymphocytes, is superficial and mostly perivascular [20, 51]. Jang E, Park M, Jeong JE, Lee JY, Kim MG. Sci Rep. 2022 May 12;12(1):7839. doi: 10.1038/s41598-022-11505-0. 1983;8(6):76375. (adult rickets), anticonvulsant-induced rickets and osteomalacia, osteoporosis, renal osteodystrophy . Immunophenotypic studies with the use of advanced antibody panels may be useful in the differential diagnosis of these two forms.10 Reticulum cell sarcoma is another form of cutaneous T-cell lymphoma that may cause exfoliative dermatitis. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Ramirez GA, Yacoub MR, Ripa M, Mannina D, Cariddi A, Saporiti N, Ciceri F, Castagna A, Colombo G, Dagna L. Biomed Res Int. Kano Y, et al. 2010;88(1):608. Science. This is due to a reaction to certain medicines, a pre-existing skin condition, and sometimes cancer. 2015;56(4):298302. J Am Acad Dermatol. However, patchy, diffuse areas of postinflammatory hyperpigmentation and hypopigmentation may occur, especially in patients with darker skin.1,4 One case of posterythrodermic generalized vitiligo beginning six weeks after the onset of exfoliative dermatitis has been reported.29,30 Residual eruptive nevi and keloid formation are rare sequelae. The EuroSCAR-study. Patients can be extremely suffering because of the pain induced by skin and mucosal detachment. 585600. 2010;5:39. It characteristically demonstrates diffuse erythema and scaling of greater than 90% of the body surface area. 2012;97:14966. It can lead to pain, appear on large parts of the body and may require hospitalization. Pregnancy . Harr T, French LE. Increased peripheral blood flow can result in high-output cardiac failure. Eur J Clin Microbiol Infect Dis. For the prevention of deep venous thrombosis; usually low molecular weight heparin at prophylactic dose are used. Notably, Agr inhibitors have not yet been more rigorous pre-clinical testing using the established analyzed using rigorous testing with systemic applica standards for drug development. Other clinical findings include lymphadenopathy, hepatomegaly, splenomegaly, edema of the foot or ankle4,6 and gynecomastia.19, The scaling that occurs in exfoliative dermatitis can have severe metabolic consequences, depending on the intensity and the duration of the scaling. (See paras 3 - 42 and 3- 43.) Int J Dermatol. Previous vol/issue. Paradisi A, et al. 2011;66(3):3607. 2010;2(3):18994. Here we provide a systematic review on frequency, risk factors, pathogenesis, clinical features and management of patients with drug induced ED. Supportive and specific care includes both local and systemic measures, as represented in Fig. 1990;126(1):437. Exfoliative dermatitis, also known as erythroderma, is an uncommon but serious skin disorder that family physicians must be able to recognize and treat appropriately. Some of these patients undergo spontaneous resolution. Despite improved knowledge of the immunopathogenesis of these conditions, immune-modulatory therapies currently used have not been definitively proved to be efficacious [49, 107], and new strategies are urgently needed. Bookshelf Acute generalized exanthematous pustulosis (AGEP) is characterized by acute erythematous skin lesions, generally arising in the face and intertriginous areas, subsequently sterile pinhead-sized nonfollicular pustules arise and if they coalesce, may sometimes mimic a positive Nikolskys sign and in this case the condition may be misinterpreted as TEN [86]. Sokumbi O, Wetter DA. It might be. To confirm ATT induced erythroderma and narrow down the offending agents, sequential rechallenge with ATT was done and again these patients had similar lesions erupt all over the body only with isoniazid and pyrazinamide. 2012;366(26):2492501. Severe adverse cutaneous reactions to drugs. Clinical features; Delayed type hypersensitivity; Drug hypersensitivity; Erythema multiforme; Exfoliative dermatitis; Lyells syndrome; Pathogenesis; StevensJohnson syndrome; Therapy; Toxic epidermal necrolysis. In: Eisen AZ, Wolff K, editors. The velocity of infusion should be regulated according to patients arterial pressure with the aim of 30mL/h urinary output (1mL/kg/h in case of a child). Am J Dermatopathol. The clinical course of patients with malignancies depends on the type of malignancy and the response to appropriate therapy. Interstitial nephritis is common in DRESS syndrome, occurring roughly in 40% of cases, whereas pre-renal azotemia may occur in SJS and TEN. EMM is characterizes by target lesions, circular lesions of 1-2cm of diameter, that are defined as typical or atypical that tends to blister. Toxic epidermal necrolysis associated with Mycoplasma pneumoniae infection. This is particularly true for patients with many comorbidities and poli-drug therapy, where it is advisable to monitor liver and kidney toxicity and to avoid Vitamin A excess [99]. Pemphigus vulgaris, paraneoplastic pemphigus, bullous pemphigoid and linear IgA dermatosis have to be considered. Unfortunately, the clinical picture does not contribute to an understanding of the underlying cause. 2006;6(4):2658. A switch to oral therapy can be performed once the mucosal conditions improve. Reticuloendothelial neoplasms, as well as internal visceral malignancies, can produce erythroderma, with the former being the more predominant cause. doi: 10.4065/mcp.2009.0379. Toxic epidermal necrolysis and StevensJohnson syndrome. Article 2010;85(2):131138. An epidemiologic study from West Germany. Exfoliative Dermatitis is a serious skin cell disorder that requires early diagnosis and treatment. In the hospital, special attention must be given to maintaining temperature control, replacing lost fluids and electrolytes, and preventing and treating infection. Retrospective review of StevensJohnson syndrome/toxic epidermal necrolysis treatment comparing intravenous immunoglobulin with cyclosporine. Annu Rev Pharmacol Toxicol. (5.7, 8.1, 8.3) ADVERSE REACTIONS The most commonly reported adverse drug reactions (ADRs), reported in more than 20% of the patients and greater than placebo were skin reactions and diarrhea . 2012;12(4):37682. Toxic epidermal necrolysis (Lyell syndrome). Corticosteroids could also reduce the amount of keratinocytes apoptosis and the activation of caspases [105]. Staphylococcal Scalded Skin Syndrome: criteria for Differential Diagnosis from Lyells Syndrome. 2012;2012:915314. Int J Dermatol. Even though there is not a significant increase in the number of T cells infiltrating the skin of TEN patients, it was found that their role is crucial, even more than HLAs types. It was used with success in different case reports [114116]. A population-based study with particular reference to reactions caused by drugs among outpatients. Med J Armed Forces India. Recurrent erythema multiforme in association with recurrent Mycoplasma pneumoniae infections. Possible involvement of CD14+CD16+monocyte lineage cells in the epidermal damage of StevensJohnson syndrome and toxic epidermal necrolysis. Smith SD, et al. 1996;134(4):7104. Fritsch PO. It should be used only in case of a documented positivity of cultural samples. Erythema multiforme (EM), Stevens- Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are the main clinical presentations of drug induced ED. Wolkenstein P, et al. Drug induced exfoliative dermatitis (ED) are a group of rare and severe drug hypersensitivity reactions (DHR) involving skin and usually occurring from days to several weeks after drug exposure. Schwartz RA, McDonough PH, Lee BW. CAS Granulysin as a marker for early diagnosis of the StevensJohnson syndrome. Rifampin, paracetamol, metronidazole, paclitaxel, erythromycin, and ibuprofen have all been reported to cause bullous FDE. It is challenging to diagnose this syndrome due to the variety . d. Cysts and tumors. Kirchhof MG et al. Applications of Immunopharmacogenomics: Predicting, Preventing, and Understanding Immune-Mediated Adverse Drug Reactions. J Dtsch Dermatol Ges. 1993;129(1):926. Erythema multiforme (EM), Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are the main clinical presentations of drug induced ED. Google Scholar. Joint Bone Spine. Kamaliah MD, et al. erythroderma, exfoliative dermatitis, and fixed drug reactions) 4, 5 and . Students also viewed Nostra aetate - Summary Theology: the basics Principles of Risk Management and Insurance Chapters 1-4 This compressed maturation process results in an overall greater loss of epidermal material, which is manifested clinically as severe scaling and shedding. Dermatologist and/or allergist should confirm the diagnosis, individuate the culprit agent, give indications about skin management and necessity to obtain theconsultationofthe ENT specialist, the gynecologist/urologist, the ophthalmologist and/or the pulmonologist in the case of mucosal involvement. Szary syndrome, the leukemic variant of mycosis fungoides, is also associated with exfoliative dermatitis. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Part of 2008;23(5):54750. Furosemide or ethacrynic acid may be required to maintain an adequate urinary output [90]. Skin eruptions caused by CBZ occur in 24% of the patients on this therapy and include pruritic and erythematous rashes, urticaria, photosensitivity reactions, alterations in skin pigmentation, exfoliative dermatitis, and toxic epidermal necrolysis View on Wiley ncbi.nlm.nih.gov Save to Library Create Alert Cite 12 Citations Citation Type Analysis for circulating Szary cells may be helpful, but only if the cells are identified in unequivocally large numbers. However, according to a consensus definition [54], EMM syndrome has been separated from SJS/TEN spectrum. In SJS, SJS/TEN and TEN the efficacy of corticosteroids is far from being demonstrated. For SJS/TEN, corticosteroids are the cornerstone of treatment albeit efficacy remains unclear. Both DRESS and SJS may have increased liver enzymes and hepatitis, but they occur in only 10% of cases of SJS compared to 80% of DRESS. Medication use and the risk of StevensJohnson syndrome or toxic epidermal necrolysis. Nassif A, et al. Wetter DA, Davis MD. Some anti-seizure medicines have also been known to cause exfoliative dermatitis. 2000;22(5):4137. Antibiotic therapy. Delayed reactions to drugs show levels of perforin, granzyme B, and Fas-L to be related to disease severity. Partial to full thickness epidermal necrosis, intraepidermal vesiculation or subepidermal blisters, due to spongiosis and to the cellular damage of the basal layer of the epidermis, can be present in the advanced disease [49] Occasionally, severe papillary edema is also present [20]. Allergy. Umbilical cord mesenchymal stem cell transplantation in drug-induced StevensJohnson syndrome. SCORTEN: a severity-of-illness score for toxic epidermal necrolysis. Common acute symptoms include abdominal pain or cramps, nausea, vomiting, and diarrhea, jaundice, skin rash and eyes dryness and therefore could mimic the prodromal and early phase of ED. Both hyperthermia and hypothermia are reported. Guidelines for the management of drug-induced liver injury[J]. Accessibility 1). During the acute reaction, diagnosis of ED is mainly based on clinical parameters. Clin Mol Allergy 14, 9 (2016). Abstract Acute interstitial nephritis associated with hepatitis, exfoliative dermatitis, fever and eosinophilia is uncommon. Exfoliative dermatitis is a disease process in which most, and sometimes all, of the skin is involved in erythematous inflammation resulting in massive scaling.1 A variety of diseases and other exogenous factors may cause exfoliative dermatitis. A drug eruption may start as a rash but eventually progress to more generalized exfoliative dermatitis. Gastrointestinal: pancreatitis, glossitis, dyspepsia. Erythema multiforme and toxic epidermal necrolysis. Toxic epidermal necrolysis: review of pathogenesis and management. In conclusion we suggest that therapy with cyclosporine is valuable option with a dosage of 35mg/kg oral or iv for 7days. Toxic epidermal necrolysis: Part II Prognosis, sequelae, diagnosis, differential diagnosis, prevention, and treatment. Skin conditions. 2002;65(9):186170. In some studies, the nose and paranasal area are spared. Infliximab: chimeric IgG monoclonal anti-TNF- antibody. Trigger is an exotoxin released by Staphylococcus aureus [83]. doi: 10.4103/0019-5154.39732. PubMed PubMed In general, they occur more frequently in women, with a male to female ratio of 0.6 [22]. The most common of these are psoriasis, atopic dermatitis, seborrheic dermatitis, contact dermatitis and pityriasis rubra pilaris. Drug-induced exfoliative dermatitis is usually short-lived once the inciting medication is withdrawn and appropriate therapy is administered. 1996;44(2):1646. In: Eisen AZ, Wolff K, editors. Am Fam Physician. Genome-wide association study identifies HLA-A* 3101 allele as a genetic risk factor for carbamazepine-induced cutaneous adverse drug reactions in Japanese population. Cutaneous graft-versus-host diseaseclinical considerations and management. In patients with SJS/TEN increased serum levels of retinoid acid have been found. Increased level of retinoid acid could be responsible for keratinocytes apoptosis [99]. Toxic epidermal necrolysis: effector cells are drug-specific cytotoxic T cells. CAS Autologous transplantation of mesenchymal umbilical cord cells seems also to be highly efficacious [102]. Atypical target lesions manifest as raised, edematous, palpable lesions with only two zones of color change and/or an extensive exanthema with a poorly defined border darker in the center(Fig. Incidence and drug etiology in France, 1981-1985. Eosinophils from Physiology to Disease: A Comprehensive Review. Open trial of ciclosporin treatment for StevensJohnson syndrome and toxic epidermal necrolysis. Beneficial effect of plasma exchange in the treatment of toxic epidermal necrolysis: a series of four cases. Morel E, et al. Blood counts and bone marrow studies may reveal an underlying leukemia. PubMed Central Insidious development of the erythroderma, progressive debilitation of the patient, absence of previous skin disease and resistance to standard therapy are features that may suggest an underlying malignancy.6,11, Erythroderma is also associated with disorders that cannot easily be classified into groups. . Clinical and Molecular Allergy They usually have fever, are dyspneic and cannot physiologically feed. Springer Nature. Google Scholar. Clin Exp Dermatol. 2013;69(4):37583. In case of an oral mucositis that impairs nutrition, it is indicated to position a nasogastric tube. The lesions consist of pruritic, annular papules, vesicles, and bullae that are found in groups, clinically it is similar to dermatitis herpetiformis, without a gluten-sensitive enteropathy [85].
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