Exfoliative Dermatitis - Noninfectious Inflammatory Dermatoses

EXFOLIATIVE DERMATITIS

Exfoliative dermatitis is a serious condition characterized by pro-gressive inflammation in which erythema and scaling occur in a more or less generalized distribution. It may be associated with chills, fever, prostration, severe toxicity, and an itchy scaling of the skin. There is a profound loss of stratum corneum (ie, outer-most layer of the skin), which causes capillary leakage, hypopro-teinemia, and negative nitrogen balance. Because of widespread dilation of cutaneous vessels, large amounts of body heat are lost, and exfoliative dermatitis has a marked effect on the entire body.

Exfoliative dermatitis has a variety of causes. It is considered to be a secondary or reactive process to an underlying skin or sys-temic disease. It may appear as a part of the lymphoma group of diseases and may precede the appearance of lymphoma. Preexist-ing skin disorders that have been implicated as a cause include psoriasis, atopic dermatitis, and contact dermatitis. It also appears as a severe reaction to many medications, including penicillin and phenylbutazone. The cause is unknown in approximately 25% of cases (Odom et al., 2000).

Clinical Manifestations

This condition starts acutely as a patchy or a generalized erythe-matous eruption accompanied by fever, malaise, and occasionally gastrointestinal symptoms. The skin color changes from pink to dark red. After a week, the characteristic exfoliation (ie, scaling) begins, usually in the form of thin flakes that leave the underlying skin smooth and red, with new scales forming as the older ones come off. Hair loss may accompany this disorder. Relapses are common. The systemic effects include high-output heart fail-ure, intestinal disturbances, breast enlargement, elevated levels of uric acid in the blood (ie, hyperuricemia), and temperature disturbances.

Medical Management

The objectives of management are to maintain fluid and elec-trolyte balance and to prevent infection. The treatment is indi-vidualized and supportive and should be initiated as soon as the condition is diagnosed.

The patient may be hospitalized and placed on bed rest. All medications that may be implicated are discontinued. A com-fortable room temperature should be maintained because the pa-tient does not have normal thermoregulatory control as a result of temperature fluctuations caused by vasodilation and evapora-tive water loss. Fluid and electrolyte balance must be maintained because there is considerable water and protein loss from the skin surface. Plasma volume expanders may be indicated.

Nursing Management

Continual nursing assessment is carried out to detect infection. The disrupted, erythematous, moist skin is susceptible to infec-tion and becomes colonized with pathogenic organisms, which produce more inflammation. Antibiotics, prescribed if infection is present, are selected on the basis of culture and sensitivity.

Hypothermia may occur because increased blood flow in the skin, coupled with increased water loss through the skin, leads to heat loss by radiation, conduction, and evaporation. Changes in vital signs are closely monitored and reported.

As in any acute dermatitis, topical therapy is used to provide symptomatic relief. Soothing baths, compresses, and lubrication with emollients are used to treat the extensive dermatitis. The pa-tient is likely to be extremely irritable because of the severe itch-ing. Oral or parenteral corticosteroids may be prescribed when the disease is not controlled by more conservative therapy. When a specific cause is known, more specific therapy may be used. The patient is advised to avoid all irritants in the future, particularly medications.