AKT · Dermatology/Dermatological emergencieslow yield

Erythroderma

Generalised inflammatory skin failure (>90% BSA erythema)

Overview

Erythema affecting >90% of the body surface — a dermatological emergency regardless of cause, because the inflamed skin loses its barrier functions (fluid, heat, protein). Causes: pre-existing dermatoses (psoriasis, eczema), drug reactions, cutaneous lymphoma (Sézary syndrome), and idiopathic.

Recognise

Widespread (>90%) erythema and scaling ("the red man"), with the skin warm and tight
Systemic consequences of skin failure: hypothermia or fever, high-output cardiac failure, dehydration, hypoalbuminaemia, and infection risk
Look for clues to the cause: nail/scalp changes (psoriasis), lichenification (eczema), lymphadenopathy + atypical cells (Sézary), a new drug

Red flags

Haemodynamic instability, hypothermia, high-output failure, secondary sepsis — admit

Differentials & how to tell them apart

Psoriasis (erythrodermic)prior plaque psoriasis, nail pitting; can be precipitated by steroid withdrawal

Atopic eczemaatopy history, lichenification, flexural emphasis

Drug reactionrecent culprit drug, eosinophilia

Cutaneous T-cell lymphoma (Sézary syndrome)erythroderma + lymphadenopathy + circulating atypical (Sézary) cells

Clinical image

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Erythroderma — clinical imagesDermNet

Investigations

Bloods (FBC, U&E, albumin, LFTs, blood film for Sézary cells), skin biopsy ± repeat to find the cause, drug history; monitor temperature, fluids and haemodynamics.

Management

Admit for supportive skin failure care + identify and treat the underlying cause

1Admit. Supportive management of skin failure — warming, fluid and electrolyte balance, emollients, monitor for high-output cardiac failure and infection.Gate: Identify the underlying cause before reaching for systemic steroids — in psoriasis-driven erythroderma, systemic corticosteroids can trigger rebound/generalised pustular psoriasis on withdrawal
2Treat the cause: stop the culprit drug, optimise the underlying dermatosis, investigate for cutaneous lymphoma if persistent/unexplained.

Supportive (warming, fluids, emollients) — restore the barrier; manage fluid/temperature/protein loss

Treat the underlying cause — stop a culprit drug; treat the psoriasis/eczema (avoid systemic steroids in psoriasis-driven disease)

Antibiotics if secondarily infected — sepsis is a leading complication

Key points

Think of erythroderma as skin failure — the systemic complications (fluid, heat, protein, infection) are what kill, not the redness itself. Beware systemic steroids if psoriasis is the cause.

Monitor & prognosis

Temperature, fluid balance, albumin, haemodynamics, infection.

Depends on the cause; the acute state carries real mortality from its complications.

Source: NICE CKS; UK dermatology guidance