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. The scales may be small or large, superficial or deep. Ned Tijdschr Geneeskd. Fitzpatricks dermatology in general medicine. The authors declare that they have no competing interests. Am J Clin 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. Frequently reported adverse events of rebamipide compared to other drugs for peptic ulcer and gastroesophageal reflux disease. Arch Dermatol. Keywords: The most common of these are psoriasis, atopic dermatitis, seborrheic dermatitis, contact dermatitis and pityriasis rubra pilaris. -. 1996;134(4):7104. Gout and its comorbidities: implications for therapy. TEN is characterized by full-thickness epidermal necrosis with an evident epidermal detachment and sloughing caused by necrosis of keratinocytes following apoptosis [49, 52]. Gastrointestinal: pancreatitis, glossitis, dyspepsia. Toxic epidermal necrolysis associated with severe cytomegalovirus infection in a patient on regular hemodialysis. Exfoliative dermatitis (ED) is defined as diffuse erythema and scaling of the skin involving more than 90% of the total body skin surface area. 2007;56(5 Suppl):S1189. This has been called the nose sign.18, Once the erythema is well established, scaling inevitably follows (Figure 1). Some of these patients undergo spontaneous resolution. 2011;38(3):23645. Am J Dermatopathol. It is recommended to use 1.5mg/kg hydrocortisone. HLA-B* 5801 allele as a genetic marker for severe cutaneous adverse reactions caused by allopurinol. 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. Two Cases in Adult Patients. Arch Dermatol. 2013;168(3):53949. Cookies policy. A significant number of these patients eventually progress to cutaneous T-cell lymphoma.8, Clinically, the first stage of exfoliative dermatitis is erythema, often beginning as single or multiple pruritic patches, involving especially the head, trunk and genital region. Mona-Rita Yacoub. 2010;5:39. 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. The prognosis of cases associated with malignancy typically depends on the outcome of the underlying malignancy. Erythema multiforme (photo reproduced with permission of Gary White, MD): typical target lesions (white arrows) together with atypical two-zoned lesions (black arrows). A rare case of toxic epidermal necrolysis with unexpected Fever resulting from dengue virus. Ophthalmologic consultations must be repeated at fixed intervals to avoid the appearance of conjunctival irreversible complications such as chronic conjunctivitis with squamous metaplasia, trichiasis, symblepharon, punctate keratitis and sicca syndrome. Br J Dermatol. Br J Dermatol. Tohyama M, et al. Fernando SL. For the prevention of deep venous thrombosis; usually low molecular weight heparin at prophylactic dose are used. Once established the percentage of the involved skin, lactate Ringer infusion of 12mL/Kg/% of involved skin must be started during the first 24h [91]. Szary syndrome, the leukemic variant of mycosis fungoides, is also associated with exfoliative dermatitis. 2013;168(3):55562. Both hyperthermia and hypothermia are reported. In conclusion we suggest that therapy with cyclosporine is valuable option with a dosage of 35mg/kg oral or iv for 7days. Posadas SJ, et al. Read this article to find out all its symptoms, causes and treatments. 2006;6(4):2658. Chung WH, et al. Bullous dermatoses can be debilitating and possibly fatal. The therapeutic approach of EMM, SJS, TEN depends on extension of skin, mucosal involvement and systemic patients conditions. In EM a lymphocytic infiltrate (CD8+ and macrophages), associated with vacuolar changes and dyskeratosis of basal keratinocytes, is found along the dermo-epidermal junction, while there is a moderate lymphocytic infiltrate around the superficial vascular plexus [20]. Kaffenberger BH, Rosenbach M. Toxic epidermal necrolysis and early transfer to a regional burn unit: is it time to reevaluate what we teach? A multicentre study to determine the value and safety of drug patch tests for the three main classes of severe cutaneous adverse drug reactions. Clin Mol Allergy 14, 9 (2016). c. Amyloidosis. Schwartz RA et al. PubMed Death ligand TRAIL, secreted by CD1a+and CD14+cells in blister fluids, is involved in killing keratinocytes in toxic epidermal necrolysis. Toxic epidermal necrolysis: Part I Introduction, history, classification, clinical features, systemic manifestations, etiology, and immunopathogenesis. 1991;127(6):83942. Pathophysiology DIP. Roujeau JC, et al. Br J Dermatol. Paradisi et al. PubMedGoogle Scholar. Fitzpatricks dermatology in general medicine. 22 Abacavir-induced hypersensitivity syndrome is strongly associated with HLA-B*5701 during treatment . No uniformity of opinion exists concerning the best treatment for cutaneous T-cell lymphoma. J Am Acad Dermatol. Before AR 40-501 14 June 2017 33 e. Dermatitis herpetiformis. For the calculation, available values on vital and laboratory parameters within the first 3days after admission to the first hospital are considered when the reaction started outside the hospital (community patients) or at the date of hospitalization for in-hospital patients. Continue Reading. Schwartz RA, McDonough PH, Lee BW. Diagnosis in a routine setting is based on patch test (PT) while skin test (prick and intradermal tests) with a delayed reading are contraindicated in these patients [72]. The exact role of FasL in the pathogenesis of toxic epidermal necrolysis is still questionable especially because a correlation between serum FasL levels and disease severity has not been established and because its levels have been found to be increased also in drug-induced hypersensitivity syndrome and maculopapular eruption [36]. Paul C, et al. Recurrent erythema multiforme in association with recurrent Mycoplasma pneumoniae infections. The SCORTEN scale is based on a minimal set of parameters as described in the following table. 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. loss of taste Derm: stevens-johnson syndrome, toxic epidermal necrolysis, rash, exfoliative dermatitis, hair . The approach to treatment should include discontinuation of any potentially causative medications and a search for any underlying malignancy. Detection of a herpes simplex viral antigen in skin lesions of erythema multiforme. Exfoliative dermatitis, including Stevens-Johnson syndrome, drug rash with eosinophilia and systemic symptoms, and toxic epidermal necrolysis, has occurred with anti-PD-1/PD-L1 treatments. Gen Dent. The diagnosis of GVDH requires histological confirmation [87]. Med Sci Monit. https://doi.org/10.1186/s12948-016-0045-0, DOI: https://doi.org/10.1186/s12948-016-0045-0. 2003;21(1):195205. MalaCards based summary: Exfoliative Dermatitis is related to holocarboxylase synthetase deficiency and dermatitis, and has symptoms including exanthema An important gene associated with Exfoliative Dermatitis is SPINK5 (Serine Peptidase Inhibitor Kazal Type 5). In order to rule out autoimmune blistering diseases, direct immune fluorescence staining should be additionally performed to exclude the presence of immunoglobulin and/or complement deposition in the epidermis and/or the epidermal-dermal zone, absent in ED. Analysis for circulating Szary cells may be helpful, but only if the cells are identified in unequivocally large numbers. Infliximab: chimeric IgG monoclonal anti-TNF- antibody. Interleukin (IL)-1, IL-2, IL-8, intercellular adhesion molecule 1 (ICAM-1), tumor necrosis factor and interferon gamma are the cytokines that may have roles in the pathogenensis of exfoliative dermatitis.2. A case of toxic epidermal necrolysis with involvement of the GI tract after systemic contrast agent application at cardiac catheterization. Journal of Pharmaceutical Research and health Care. Mucosal involvement could achieve almost 65% of patients [17]. An epidemiologic study from West Germany. Check the full list of possible causes and conditions now! EDs are serious and potentially fatal conditions. It characteristically demonstrates diffuse erythema and scaling of greater than 90% of the body surface area. J Am Acad Dermatol. Bourgeois GP, et al. In conclusion, therapy wth IVIG should be started within the first 5days and an high-dosage regimen should be preferred (2.54g/kg for adults and 0.251.5g/kg in children divided in 35days). Erythema multiforme (EM), StevensJohnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are the main clinical presentations of drug induced ED. In more severe cases corneal protective lens can be used. 2010 Oct;35(7):723-8. doi: 10.1111/j.1365-2230.2009.03718.x. Heat loss is another major concern that accompanies a defective skin barrier in patients with exfoliative dermatitis. Br J Dermatol. Poor relevance of a lymphocyte proliferation assay in lamotrigine-induced StevensJohnson syndrome or toxic epidermal necrolysis. Epilepsia. Huff JC, Weston WL, Tonnesen MG. Erythema multiforme: a critical review of characteristics, diagnostic criteria, and causes. 19 Key critical interactions are discussed below for each mpox antiviral. A recent review [111] on 33 pediatric cases of TEN and 6 cases of SJS/TEN overlap showed that therapy with IVIG with a dosage of 0.251.5g/kg for 5days resulted in 0% mortality rate and faster epithelization. 2013;69(4):37583. Supportive and specific care includes both local and systemic measures, as represented in Fig. 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. Next vol/issue 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. Ayangco L, Rogers RS 3rd. (2.4, 5.6) Embryo-fetal Toxicity: Can cause fetal harm. Kavitha Saravu. Stamp LK, Chapman PT. A population-based study of StevensJohnson syndrome. EM is a self-limited skin condition mainly associated with infections and drugs [53, 54]. 2010;163(4):84753. In serious cases invasive ventilation can be necessary for ARDS. 1992;11(3):20710. Erythema multiforme StevensJohnson syndrome and toxic epidermal necrolysis. Science. CAS Targeting keratinocyte apoptosis in the treatment of atopic dermatitis and allergic contact dermatitis. 1983;8(6):76375. Clipboard, Search History, and several other advanced features are temporarily unavailable. Roujeau JC, et al. statement and What are Drug Rashes? [113] retrospectively compared mortality in 64 patients with ED treated either with iv or oral Cys A (35mg/kg) or IVIG (25g/Kg). Ann Pharmacother. 2010;62(1):4553. Chan HL, et al. ADRJ,2015,17(6):464-465. Ann Burns Fire. Patients with carcinoma of the colon, lung, prostate and thyroid have presented with erythroderma. Polak ME, 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. of Internal Medicine, University of Bari, Bari, Italy, Andrea Nico,Elisabetta Di Leo,Paola Fantini&Eustachio Nettis, You can also search for this author in Roujeau JC, Stern RS. Clinical classification of cases of toxic epidermal necrolysis, StevensJohnson syndrome, and erythema multiforme. 2012;12(4):37682. Barbaud A. Wetter DA, Camilleri MJ. In: Eisen AZ, Wolff K, editors. A catabolic state thus ensues, which is often responsible for significant weight loss. Clinical, etiologic, and histopathologic features of StevensJohnson syndrome during an 8-year period at Mayo Clinic. Arch Dermatol. HLA-A* 3101 and carbamazepine-induced hypersensitivity reactions in Europeans. . A central role in the pathogenesis of ED is played by CD8+ lymphocytes and NK cells. Exfoliative Dermatitis is a serious skin cell disorder that requires early diagnosis and treatment. 2014;71(2):27883. 7 DRUG INTERACTIONS 7.1 PDE-5-Inhibitors and sGC-Stimulators 7.2 Ergotamine 8 USE IN SPECIFIC POPULATIONS 8.1 Pregnancy 8.2 Lactation 8.4 Pediatric Use 8.5 Geriatric Use 10 OVERDOSAGE 10.1 Signs and Symptoms, Methemoglobinemia 10.2 Treatment of Overdosage 11 DESCRIPTION 12 CLINICAL PHARMACOLOGY 12.1 Mechanism of Action 12.2 Pharmacodynamics 12. . Yacoub, MR., Berti, A., Campochiaro, C. et al. 2007;48(5):10158. Gueudry J, et al. These patches tend to spread until, after a matter of days or weeks, most of the skin surface is covered with an erythematous, pruritic eruption. Main discriminating factors between EMM, SJS, SJS-TEN, TEN and SSSS is summarized in Table3 [84]. J Am Acad Dermatol. Indian J Dermatol. Erythema multiforme StevensJohnson syndrome and toxic epidermal necrolysis. In addition to all these mechanisms, alarmins, endogenous molecules released after cell damage, were found to be transiently increased in SJS/TEN patients, perhaps amplifying the immune response, including -defensin, S100A and HMGB1 [47]. Exfoliative dermatitis is a rare inflammatory skin condition that is characterized by desquamation and erythema involving more than 90% of the body surface area. It might be. Paquet P, Pierard GE. Ozeki T, et al. (scFv) (directed against Dsg1/3) or AK23 (directed against Dsg3) with (as a control) or without exfoliative toxin A (ETA). Furosemide or ethacrynic acid may be required to maintain an adequate urinary output [90]. -. Google Scholar. Drug specific cytotoxic T-cells in the skin lesions of a patient with toxic epidermal necrolysis. The strength of association with the development of SJS/TEN may vary among countries and historical periods, reflecting differences in ethnicities and prescription habits among the studied populations [6164]. In more severe cases antiviral therapies should be given together with intravenous immunoglobulins [93]. In more severe cases continuous iv therapy can be necessary. Kostal M, et al. The erythrodermic form of mycosis fungoides and the Szary syndrome may also be difficult to distinguish from benign erythroderma. J Am Acad Dermatol. 2008;49(12):208791. 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. 2018 Feb;54(1):147-176. doi: 10.1007/s12016-017-8654-z. 2010;85(2):1318. J Allergy Clin Immunol. 1996;135(1):611. Br J Dermatol. Do this 2 to 3 times a week. Huang SH, et al. Kano Y, et al. . 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. Morel E, et al. Abe R, et al. New York: McGraw-Hill; 2003. p. 585600. It is challenging to diagnose this syndrome due to the variety . The incidence of erythema multiforme, StevensJohnson syndrome, and toxic epidermal necrolysis.