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).
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.
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
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 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
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.
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.