Original Article

Clinicoetiological study of 30 erythroderma

cases from tertiary center in South India
Manjunath Hulmani, B. NandaKishore, M. Ramesh Bhat, D. Sukumar, Jacintha Martis,
Ganesh Kamath, M. K. Srinath
Department of
Dermatology,
Venereology and Leprosy,
Father Muller Medical
College, Mangalore, India

ABSTRACT
Background: Erythroderma is a morphological reaction pattern of skin having many underlying causes and
finding the etiology helps in the proper management of erythroderma cases. Aim: To evaluate the clinical profile,
etiology of erythroderma and to correlate clinical diagnosis with histopathology. Materials and Methods: This
study was performed at the department of dermatology, Father Muller Medical College and Hospital, Mangalore,
South India. We studied 30 consecutive cases of erythroderma with respect to the epidemiological, clinical and
histological data. Clinicohistological correlation was analyzed for etiology of erythroderma. Results: The mean
age of onset was 52.3years with a male to female ratio of 14:1. In addition to erythroderma, other coexistent
features included pruritus, fever, lymphadenopathy, and edema. Of the preexisting dermatoses, psoriasis
was the most common(33.3%) disease followed by eczema(20%), atopic dermatitis(6.6%), pityriasis rubra
pilaris(3.3%) and druginduced erythroderma(16.6%). In 16.6% of cases, etiology could not be ascertained.
Clinicohistopathological correlation could be established in 73.3% of cases. Conclusion: Clinical features
were identical irrespective of etiology. Detailed clinicohistopathological examination helps to establish the
etiology of erythroderma.
Key words: Clinical and histopathological examinations, erythroderma, exfoliative dermatitis

INTRODUCTION
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DOI: 10.4103/2229-5178.126024
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Address for
correspondence:
Dr.Manjunath Hulmani,
Department of
Dermatology,
Srinivas Institute of
Medical Science and
Research Centre,
Mukka, Surathkal,
Mangalore574146,
India.
Email:
manjunathhulmani@gmail.
com

Erythroderma or exfoliative dermatitis is an

inflammatory disorder in which erythema and
scaling occur in a generalized distribution
involving more than 90% of the body surface.[1]
Erythroderma is a morphological reaction pattern
of skin having various underlying causes which
include preexisting skin conditions such as
psoriasis, atopic dermatitis, contact dermatitis and
systemic skin conditions including malignancy
and drug intake.[2] Finding the etiology helps in
the proper management of erythroderma cases.

MATERIALS AND METHODS

The study was conducted between July 2007 and
August 2009. Thirty successive erythrodermic
patients, admitted in Father Muller Medical
College and Hospital, Mangalore, South India,
were included in the study. Patients were
clinically evaluated with detailed history and
complete physical examination. History included
the onset and evolution of erythroderma,

Indian Dermatology Online Journal - January-March 2014 - Volume 5 - Issue 1

history of skin diseases, previous episodes of

erythroderma if any, aggravating factors, any
associated disorder and drug intake. A detailed
clinical examination was carried out to know the
various clinical manifestations and to find out the
possible causes for the erythroderma.
Classic plaques of psoriasis may be evident
in early and remitting stages of erythroderma.
Past history of silvery scaly plaques and heavier
involvement in body parts where psoriasis is
common also helped in making out psoriatic
erythroderma[Figure1]. Typical nail changes of
psoriasis and psoriatic arthritis if present are clues
to psoriasis. For atopic dermatitis as a cause, the
past history of atopy and characteristic distribution
pattern are suggestive of the disease. Pruritus
is often severe; presence of atopic epicanthal
fold of the lower eyelid and atopic cataract are
other clues for diagnosis of erythroderma due to
atopic dermatitis.Stronghistory of contact allergy,
presence of previous eczematous lesions and
also severe oozy lesions will help to diagnose
the allergic contact dermatitis as the cause of

Hulmani, et al.: Clinico-etiological study of erythroderma

and fine needle aspiration cytology (FNAC) of lymph nodes

were done. Patch testing was done where ever required. Skin
biopsy for histopathological examination was performed in all
the cases. All the findings were recorded on a predevised
proforma and compared with other studies.

RESULTS
The mean duration of onset of erythroderma was
35days(range: 3days to 6months) with shorter duration for
druginduced erythroderma. Age of the patients ranged from
19 to 84years, with mean age being 52.3years. Majority of
the patients belonged to the age group of 6069years(33.3%).
There were 28 male and two female patients, with male to
female ratio 14:1, showing very high male predominance.
The most common aggravating factors observed were winter
season (temperature range of 1525C) seen in 30% of the
cases followed by intake of drugs(23.3%), namely phenytoin,
carbamazepine, nitrazepam, glipizide and dapsone. The other
aggravating factors were ayurvedic medications (16.6%),
summer season (10%), contact with cement (6.6%), and
parthenium weed contact. Three patients(10%) had previous
episodes of erythroderma with one patient having three
episodes.

Figure1: Psoriatic erythroderma

erythroderma, which was confirmed by patch testing. Presence

of islands of normal skin within exfoliated areas, follicular horny
papules present on the dorsal area of the fingers, toes, knees,
and elbows with thick scaling of the palms and soles are the
clinical clues for an exfoliative dermatitis arising from pityriasis
rubra pilaris. For lichen planus as a cause, violaceous color, fine
reticulate scaling and presence of mucosal lesions help to clinch
diagnosis. In a case of pemphigus foliaceus, few intact bullae
with moist erosive or crusted areas, arcuate pattern of lesions,
oral ulceration, Nikolskys sign, and acantholytic cells on Tzanck
smear will help for the diagnosis. There are no special signs to
indicate that drugs are the cause of erythroderma. Ingestion of
suspected drug prior to the onset and acute onset with fever
will help in the diagnosis. Diagnosis of idiopathic erythroderma
could be made when the condition is extending over1 month in
an elderly with severe pruritus with palmoplantar keratoderma.
Cutaneous lymphoma presents with similar findings of
idiopathic erythroderma, keen histopathological examination
and followup biopsy will help to make out the diagnosis.
Laboratory investigations such as complete hemogram, blood
glucose, blood urea, serum creatinine, liver function tests and
serum electrolytes were performed. Where ever necessary,
chest radiograph, abdominal ultrasound, peripheral smear,

26

Significant lymphadenopathy was observed in 18patients(60%)

and inguinal and axillary lymph nodes were enlarged; FNAC of
inguinal lymph nodes was done in those cases and findings were
suggestive of dermatopathic lymphadenopathy. Pitting pedal
edema in nature was present in 70% of cases. Mildtomoderate
hepatomegaly seen in 13.3% of cases was related to druginduced
erythroderma. None of the patients had splenomegaly.
Nose sign, that is sparing of nose of erythema and
scaling[Figure2] was seen in 16patients(53.3%); it was not
specific to any etiology of erythroderma and seen in cases of
erythroderma of long duration. Oral mucosal congestion and
erosion was seen in four patients(13.3%) and all the four cases
were of druginduced erythroderma. Palmar involvement in
the form of scaling, erythema, hyperkeratosis, or fissuring was
seen in 22(73.3%) cases. Plantar hyperkeratosis or fissuring
was seen in 12(40%) cases. Various nail changes observed
are depicted in Figure3. Ridging of nail was the most common
finding seen in 14(46.6%) patients, other nail changes observed
were pitting in 5 (16.6%), nail discoloration in 8 (26.6%),
onycholysis in 4(13.3%), subungual hyperkeratosis in 6(20%),
onychodystrophy in 4(13.3%), shiny nails or burnished nails in
2(6.6%), and Beaus line in 4(13.3%) patients.
Fifteen patients (50%) had anemia (hemoglobin, <12 g/dl
for males and <11 g/dl for females). Eosinophilia (reference
range: 26%) was observed in 16 patients (53.3%).
Raised erythrocyte sedimentation rate (ESR) (reference
Indian Dermatology Online Journal - January-March 2014 - Volume 5 - Issue 1

Hulmani, et al.: Clinico-etiological study of erythroderma



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Figure 3: Nail changes

Figure2: Nose sign

range: 1-10 mm/h) was seen in 16 patients (53.3%).

Hypoproteinemia(normal total serum protein: 6.68.3g/dl) was
seen in 19patients(63.3%). Low blood sodium level(normal
range: 135148 mmol/L) in 15 patients (50%), decreased
potassium(normal range: 3.55 mmo/L) in five patients(16.6%),
and decreased chloride(normal range: 98110 mmol/L) was seen
in eight patients(26.6%). Peripheral smear showed eosinophilia
in 40% of the patients and 20% showed lymphocytosis. None
of the patients showed atypical lymphocytes.
Most common histopathological findings were perivascular
lymphocytic infiltrate(83.3%) followed by parakeratosis(73.3%),
acanthosis (66.6%), hyperkeratosis (50%) and Munro's
microabscess (33.3%). Presence of parakeratosis, Munro's
microabscess, hypogranulosis, suprapapillary thinning,
acanthosis and perivascular lymphocytic infiltrate was
suggestive of psoriasis. Hyperkeratosis, spongiosis,
perivascular lymphocytic infiltrate and eosinophils were
in favor of dermatitis. Presence of parakeratosis, basal
cell vacuolization, perivascular lymphocytic infiltrate and
eosinophils was suggestive of druginduced erythroderma.
Hyperkeratosis, hypergranulosis, and perivascular lymphocytic
infiltrate were suggestive of pityriasis rubra pilaris.
Table1 summarizes the causes of exfoliative dermatitis in our
study. Erythroderma due to psoriasis was seen in 10patients,
contact dermatitis was seen in six patients, druginduced
erythroderma was reported in five cases, atopic dermatitis
was seen in two cases, pityriasis rubra pilaris and exfoliative
dermatitis due to nasopharyngeal carcinoma were seen in one
case each, and idiopathic in five cases. Clinical examination
did not implicate any etiology in six cases; of these, two
cases showed histopathological impression of eczema and
in four cases, histopathology report was nonspecific and it
was reported as idiopathic erythroderma. Clinical impression
of psoriasis was done in 11 cases, of which there was
histopathological correlation to psoriasis in 10 cases and
in one case, findings were nonspecific for which diagnosis
Indian Dermatology Online Journal - January-March 2014 - Volume 5 - Issue 1

of idiopathic erythroderma was made. Of the five cases of

idiopathic erythroderma, two cases were lost to followup and
in the other three cases, biopsy was done again at followup but
the findings did not correlate with any etiology. Histopathology
helped in confirming the clinical diagnosis in 22(73.3%) patients
and did not help in 8(26.6%) patients.

DISCUSSION
This study had a very high male predominance, ratio of
male to female being 14:1.But earlier studies had shown a
ratio between 2:1 and 4:1,[1,35] reason for this could be habit
of alcohol intake and predominant out door work by male
patients which are known to exacerbate psoriasis and eczemas
respectively. Both causes constituted more than half of patients
but sample size of 30 could be small to give any conclusion
for this unusual finding.
Commonest symptoms were generalized scaling (100%),
redness (100%), chills (93.3%), malaise (93.3%) and

Table1: Etiology of erythroderma(n=30)

Etiology

Clinical
diagnosis

Psoriasis

11

Eczema

04

Histopathological
diagnosis
Psoriasis

10

Eczema

01

Eczema

02

Psoriasis

01

Nonspecific

Final
diagnosis
10
06

01

Atopic dermatitis

02

02

02

PRP

01

01

01

Drug induced

Drug induced

04

05

Nonspecific

01

Malignancy induced

01

Nonspecific

01

01

Idiopathic

06

Eczema

02

05

Nonspecific

04

Total

30

30

30

PRP: Pityriasis rubra pilaris

27

Hulmani, et al.: Clinico-etiological study of erythroderma

itching (86.6%). Fever was present in 43.3% of cases and

26.6% had oliguria. None of the patients had dermatogenic
enteropathy. Previous studies[46] had shown similar findings.
Most common aggravating factor was winter season (30%).
Treatment with topical ayurvedic or herbal medications
aggravated condition in 16.6% of patients and all patients were
of psoriatic erythroderma. Injudicious use and irritant injury
leading to koebnerization would have aggravated psoriasis
leading to erythroderma in these patients. Homeopathic
medication was implicated as a factor in one patient. An allergic
contact dermatitis to parthenium in one patient and to cement
in two patients was seen, which was confirmed by patch testing
once the erythroderma subsided.
Lymphadenopathy was seen in 17patients(56.66%). FNAC
of lymph nodes showed features of reactive hyperplasia.
Lymphadenopathy regressed over a period of 12weeks, as
the erythrodermic state was treated. In a study by Pal and
Haroon, lymphadenopathy was present in 55.5% of cases[4]
and in all cases it was dermatopathic except in one which
showed Hodgkins lymph node. Previous studies have shown
lymphadenopathy ranging from 21% to 33% of cases.[2,5,7]
Pedal edema of pitting type was observed in 70% of cases.
Increased blood flow to skin and increased permeability of
blood vessels secondary to hypoproteinemia may be causative
factors in pedal edema.[810] In all the cases, edema subsided
as erythrodermic state was controlled and supplemented with
highprotein diet.
Irrespective of etiology, clinical features of erythroderma were
almost identical. Once the erythroderma is fully established, it is
difficult to differentiate between various causes of erythroderma.
Erythema appeared first followed by scaling over a period
of 45 days. In acute cases, scales were large and easily
detachable and in chronic cases, they were of smaller size.
In a study by Kanthraj etal. showed that daily protein loss

increased by 2530% in psoriatic erythroderma and 1015%

in nonpsoriatic erythroderma.[11] Previous studies have shown
that generalized erythema and scaling are the most common
findings, seen in up to 100% of cases.[5,6] In a study by Pal,
scaling was seen in 84.4% of cases[4] and in an Indian study,
scaling in 100% and erythema in 80% of cases was observed.[6]
The nose sign of erythroderma has been reported by
Pavithran.[12] In our study, it was present in 53.3% of cases.
The reason for this phenomenon is not exactly known, but it is
suggested that it is either due to greater exposure of the area to
sunlight with its presumptive antimitotic activity or nervous habit
of frequent rubbing of nose leading to removal of scales.[13] We
did not observe any nervous habit in our patients with this sign.
Deck chair sign described in papuloerythroderma of Ofuji[14] was
not seen in any of our patients. Pal and Haroon had described
this sign in 5.5% of the erythrodermic patients.[4]
Nail changes were observed in 70% of cases. Most common
nail change was ridging of nail, followed by subungual
hyperkeratosis, pitting, Beaus lines, and nail discoloration
and dystrophy. Earlier studies had shown similar findings.[4,6]
Hemoglobin was low in 15 (50%) cases. In a study by
Bandyopadhyay etal., it was observed in 48% of cases[5] and
in 72% of cases in Pal and Haroon series.[4] Leukocytosis
was observed in 12 (40%) cases which was similar to the
findings observed in other studies. [5,15] Eosinophilia was
seen in 16 (53.3%) cases; in a study by Hasan etal., 48%
had eosinophilia.[15] Hypoproteinemia with altered albumin to
globulin ratio was demonstrated in 19(63.3%) cases. In a study
by Botella-Estrada etal., 34% of patients had this finding.[7]
Hypoproteinemia could be due to protein loss through scaling,
chronic malnutrition, or dilution due to hypervolemia.[11,16]
Elevated levels of blood urea and serum creatinine were
seen in two(6.6%) patients who were also known diabetics;
preexisting diabetes could be the cause for this finding. In

Table2: Comparison of earlier studies with present study for etiology of erythroderma
Study causes

Pal etal.[4] Rym etal.[17] Bandyopadhyay etal.[5] Sudha etal.[6] Chaudhary etal.[3] Hasan etal.[15] Present study

Psoriasis

37.8

51.25

33.33

32

40

10

33.3

Eczema

12.2

07.5

04.0

12

20

16

20.0

Ichthyosis

07.8

01.33

02

PRP

02.2

01.25

05.33

03.3

Scabies

02.2

01.25

01.33

Pemphigus foliaceus

05.6

06.25

05.33

04

Lichen planus

01.25

Atopic dermatitis

13.33

08

6.66

14

06.6

Other dermatoses

06.6

03.75

08

Drug reaction

05.5

11.25

12.00

24

10

22

16.6

Malignancy

05.5

08.75

02.67

04

6.66

04

03.3

Idiopathic

14.6

07.5

21.33

08

16.66

32

16.6

PRP: Pityriasis rubra pilaris

28

Indian Dermatology Online Journal - January-March 2014 - Volume 5 - Issue 1

Hulmani, et al.: Clinico-etiological study of erythroderma

study by Rafael etal., increased serum creatinine was observed

in 41% of cases.[7] Serum electrolyte imbalance in the form
of low sodium level in 15 (50%) cases, low potassium level
in 5(16.6%), and low chloride level in 8(26.6%) cases was
observed. This highlights the importance of the correction of
electrolyte imbalance in the management of erythroderma.
Table2 shows the comparison of previous studies with present
study for etiology of erythroderma. In five cases (16.6%),
etiological factor for erythroderma could not be determined in
spite of thorough clinical examination, blood investigations,
and histopathology. All the patients in this group were elder
adults with a long duration of erythroderma having very severe
itching. It is advised to do multiple biopsies in such cases and
it is also imperative to have longterm followup and to rule out
cutaneous lymphoma as the cause.
Histopathology helped in correlating and confirming the etiology
of erythroderma in 80% of cases and did not help in 20% of
cases. In a study by Rym etal., histopathological correlation was
found in 74% of patients;[17] in Bandyopadhyay etal., there was
correlation in 52% of cases[5] and in a study by Kondo etal., there
was 72.54% correlation.[18] Histopathologically, identification
of psoriasis as the underlying cause of erythroderma is more
successful than elucidation of other etiologies.

4.
5.
6.

7.

8.
9.

10.
11.

12.
13.
14.
15.
16.

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Cite this article as: Hulmani M, NandaKishore B, Bhat MR, Sukumar D,

Martis J, Kamath G, Srinath MK. Clinico-etiological study of 30
erythroderma cases from tertiary center in South India. Indian Dermatol
Online J 2014;5:25-9.
Source of Support: Nil, Conflict of Interest: None declared.

29

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