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On-line version ISSN 1806-4841
An. Bras. Dermatol. vol.81 no.3 Rio de Janeiro June 2006
CLINICAL, EPIDEMIOLOGICAL, LABORATORY AND THERAPEUTIC INVESTIGATION
Exfoliative dermatitis: clinical and etiologic study of 58 cases*
Rogério Nabor KondoI; Airton dos Santos GonII; Lorivaldo MinelliIII; Mauro Filgueiras MendesIV; Rubens PontelloV
IMD. Resident in Dermatology at the
Centro de Ciências da Saúde da Universidade Estadual de Londrina
- UEL - Londrina (PR), Brazil
IIDermatologist, Master's degree in Dermatology and Assistant Professor of Dermatology at the Centro de Ciências da Saúde da Universidade Estadual de Londrina - UEL - Londrina (PR), Brazil
IIIDermatologist, PhD in Dermatology and Adjunct Professor of Dermatology at the Centro de Ciências da Saúde da Universidade Estadual de Londrina - UEL - Londrina (PR), Brazil
IVDermatologist and Adjunct Professor of Dermatology at the Centro de Ciências da Saúde da Universidade Estadual de Londrina - UEL - Londrina (PR), Brazil
VDermatologist and Adjunct Professor of Dermatology at the Centro de Ciências da Saúde da Universidade Estadual de Londrina - UEL - Londrina (PR), Brazil
BACKGROUND - Exfoliative dermatitis is
a cutaneous syndrome characterized by generalized exfoliation and erythema,
which may be result from or be associated with pre-existing skin conditions,
systemic diseases or drug reactions.
OBJECTIVE - To report the frequency of clinical features and causes associated with exfoliative dermatitis in patients seen at the Dermatology Section of the Hospital Universitário Regional do Norte do Paraná, Universidade Estadual de Londrina.
METHODS - Medical records from patients with diagnosis of exfoliative dermatitis seen at the Hospital Universitário Regional do Norte do Paraná were reviewed over a ten-year period.
RESULTS - A total of 58 patients with diagnosis of exfoliative dermatitis was assessed. Mean age was 56.89 years. The underlying disorder in 33 patients was a skin disease (psoriasis, 11 cases; contact dermatitis, 9 cases; congenital ichthyosiform erythroderma, 3 cases; seborrheic dermatitis, 5 cases; atopic dermatitis, 3 cases; pityriasis rubra pilaris, 2 cases). Drug reactions were observed in 11 patients. Etiology could not be determined in 14 cases (24%).
CONCLUSIONS - In a sample of patients attending a reference dermatology center, exfoliative dermatitis was a rare condition, and in most cases it was related to skin diseases.
Keywords: Dermatitis, exfoliative; Drug eruptions; Erythema; Psoriasis
Exfoliative dermatitis is an inflammatory skin condition characterized by erythema and scaling, involving most or all skin surface.1,2 It's a rare disease, its incidence being of one to 71 per 100000 dermatologic patients.1 Its occurrence may be associated to other skin or systemic diseases and, very often, to drug use; nevertheless, sometimes the underlying cause may not be identified, even after thorough clinical investigation.3 Besides, exfoliative dermatitis may be related to neoplastic diseases, such as cutaneous T-cell lymphomas and Sézary syndrome.1,3,4-6
Although mortality rates are low, morbidity related to exfoliative dermatitis is considerably high, since it is often a chronic disease, with debilitating signs and symptoms, such as intense pruritus and scaling.1 Thus, the importance of trying to find the etiology in patients with exfoliative dermatitis, allowing early, adequate intervention for each case.
The objective of this study is to identify and analyze the main causes of exfoliative dermatitis in a sample of patients admitted at the Dermatology Section of a teaching hospital.
PATIENTS AND METHODS
Medical records of patients with diagnosis of exfoliative dermatitis seen at the Dermatology Section of the Hospital Universitário Regional do Norte do Paraná (HURNP), Universidade Estadual de Londrina, from January 1994 to December 2003 were reviewed. Based on that data (age, sex, race, clinical history, physical examination, laboratory, histopathology, treatment and outcome), the patients were classified according to clinical and histopathologic diagnosis.
The clinical diagnosis was defined as the main clinical hypothesis, considering the history, physical exam, response to treatment and outcome. The histopathologic diagnosis was defined according to the features described in the biopsy reports, subdivided as: 1. conclusive, when the pathology gave the diagnosis; 2. compatible, when it was not conclusive but highly suggestive of a diagnosis; or 3. undefined when the changes found by pathology were unspecific.
The definite etiologic diagnosis was determined in the cases where the histopathologic diagnosis was conclusive or compatible and coincident with the clinical diagnosis, as well as in those cases where there was no biopsy but the clinical diagnosis was obvious. The etiologic diagnosis was considered undetermined in the cases where the histopathologic diagnosis was unspecific or did not coincide with the clinical diagnosis.
The data was analyzed and processed using Graph Pad Instat and Excel 2000. Statistical significance was done by c2, test, considering 5% as significant. Fischer's exact test was used when the frequencies expected to be lower than five were analyzed.
Fifty-eight medical records with the diagnosis of exfoliative dermatitis were identified in that, 37 were males, 21 females. The most prevalent age group was above 40 years, mean age at diagnosis 56.89 years (Chart 1). The main laboratory abnormalities found were anemia, hypoproteinemia, eosinophilia and a rise in serum creatinine (Table 1).
Sixty-eight biopsies were performed in 51 patients (three had two biopsies, and seven, three biopsies). The histopathologic diagnosis was classified as conclusive or compatible in 37 patients (72.54%) and unspecific in 14 patients (27.45%). The seven patients who did not have biopsies were children aged under one year, whose diagnosis of seborrheic dermatitis (four cases) and atopic dermatitis (three cases) were clinically established.
The final etiologic diagnosis according to the previously established criteria could be determined in 44 patients. The most frequent etiologies associated to exfoliative dermatitis in this study were psoriasis and drug induced eruptions, with eleven cases each. Sulfonylureas were the drugs most frequently associated with skin reactions, with three cases (Table 2).
Patients with exfoliative dermatitis usually present with a variable degree of compromise in general health, seen in the laboratory as anemia, malnourishment and other metabolic problems. The patients of this study proved to have laboratory abnormalities such as anemia, eosinophilia, hypoproteinemia and a rise in serum creatinine.
Regarding age, it is known that exfoliative dermatitis may be found since the neonatal period,7 when the prevalence is low, and it is most commonly seen over 50 years.3,8 Previous studies also show a higher incidence in males.2,3,8 In this study, the subset of patients older than 40 prevailed significantly (48-58, 82.75%) as compared to the frequency of patients under that age group (p< 0.05). Males prevailed (37/58), but this was not statically significant (p> 0.05).
Identifying the etiology in every case of exfoliative dermatitis is not always possible. The correlation between the clinical presentation and the etiology in exfoliative dermatitis is usually poor, due to the fact that changes specific to dermatosis or drug reactions are frequently masked by unspecific changes induced by exfoliative dermatitis.3 A conclusive clinical-histological correlation may thus demand several biopsies.9 In different international studies, the rates of final etiologic diagnosis based on histopathology varied from 15%10 to 43%11 of cases submitted to biopsy. In this study, histology was useful for the final diagnosis in 37 patients (72.54% of cases submitted to biopsy). This difference seen in various studies may be due to patient characteristics, which vary in each service. Nevertheless the importance of the histopathologic examination to determine the etiology of exfoliative dermatitis is clear.
Many studies have tried to identify the causes related to exfoliative dermatitis in different populations.3,8,10-14 In most of them, exfoliative dermatitis was related to the exacerbation of cutaneous diseases. Pal and Haroon,8 studying 90 cases in Pakistan, found a defined cutaneous underlying disease in 74.4% of patients, drug reactions in 5.5%, malignancy in 5.5% and undetermined causes in 14.6 % of cases. In Germany, Eugster et al.13 assessed 64 patients and observed that defined underlying dermatosis, followed by drug reactions, were also the most common causes, in 58% and 16% of cases, respectively. In Brazil, Vasconcelos et al.12 assessed 247 cases of exfoliative dermatitis and observed that psoriasis was the most frequent underlying disease (44. 9%), followed by drug reaction (7.3%). The present study corroborated such data skin disease was the most common cause (75% or 33/44 of cases with a defined etiology), this finding being significant in regard to non dermatologic causes, which corresponded to p<0.05.
Of the cutaneous diseases, psoriasis was the most common underlying disease found in this study (18.97%), although not statistically significant when compared to other skin conditions (p >0.05). Other studies also showed psoriasis as the most prevalent causal dermatosis in exfoliative dermatitis,3,10,12 what may turn it into the main cause of exfoliative dermatitis. On the other hand, the fact that this study was developed at a hospital that is a referral center for the use and free dispensing of systemic retinoids may have contributed for the selection of patients with more severe psoriasis.
In the group of drug-reaction-induced dermatitis, the most common drugs are allopurinol, carbamazepine, penicillin, gold and isoniazid, but many different classes of drugs may be responsible for the disease.1,3 In this series, sulfonylurea was the most frequently involved drug, with three cases. There are frequent reports of neoplasm-associated exfoliative dermatitis, including gastric carcinoma, laryngeal carcinoma, lymphomas (Hodgkin´s, non-Hodgkin´s, cutaneous T-cell lymphoma) and hematological disorders (leukemias and myelodysplasias), although no such cases were seen in this study.1,2,4,5 This may be due to the service characteristic, which does not provide specific care for cancer patients who are seen at an oncology hospital nearby.
Even after exhaustive investigation, there were cases in which the etiology of the exfoliative dermatitis remained uncertain. In cases with undetermined cause, strict clinical and histological follow-up are mandatory, due to the possibility of omission of drug intake or slow progression of cutaneous lymphoma.3
At the Hospital Universitário da Universidade Estadual de Londrina (HURNP), exfoliative dermatitis is an uncommon syndrome, most patients being over 40 years and most cases associated to preexisting skin conditions.
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2. Burton JL. Erythroderma. In: Rook AJ, Champion RH, Burton JL, Ebling FJG, eds. Textbook of Dermatology. 5th ed. Oxford : Blackwell Scientific Publications; 1992. p.584-8. [ Links ]
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10. Seghal VN, Srivastava G. Exfoliative dermatitis. A prospective study of 80 patients. Dermatologica. 1986;173:278-84. [ Links ]
11. King LE, Dufresne RG, Lovett GL, Rosin MA. Erythroderma: review of 82 cases. South Med J. 1986;79:1210-5. [ Links ]
12. Vasconcelos C, Domingues PP, Aoki V, Miyake RK, Sauaia N, Martins JEC. Erythroderma: analysis of 247 cases. Rev Saude Publica. 1995;29:177-82. [ Links ]
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14. Sigurdsson V, Toonstra J, van Vlonten WA . Erythroderma. A clinical and follow-up study of 102 patients with special emphasis on survival. J Am Acad Dermatol. 1996;35:56-7. [ Links ]
Rogério Nabor Kondo
Rua Presidente Gaspar Dutra, 94 Jd. Alto da Boa Vista
86600-000 Rolândia - PR
Tel: +55 (43) 3256-9415 / Fax: +55 (43) 3258-1685
Received on December 21, 2004.
Approved by the Consultive Council and accepted for publication on April 08, 2006.
Conflict of interest: None
*Work done at Dermatology Division, Centro de Ciências da Saúde da Universidade Estadual de Londrina - UEL - Londrina (PR), Brazil.