27

CASE REPORT

ERYTHRODERMA CAUSED DRUG ALLERGIES

Asrawati Sofyan, Sitti Nur Rahmah, Asnawi Madjid


Department of Dermatovenereology Medical Faculty of Hasanuddin University / Wahidin
Sudirohusodo Hospital Makassar
















ABSTRACT
Erythroderma is inflammation skin disease characterized by
erythema and scales almost or all over the body. Erythroderma is
Caused by many etiologies such as extended skin diseases, allergic
drug, systemic diseases and idiopathic. About 5-40% erythordermic
caused by allergic drug. Regardless of the underlying disease,
eryhtrodermic patient should be hospitalized. Erythroderma due to
allergic drug has a good prognosis, if the offending drug could be
established and withdrawn. We reported a case of erythroderma due to
drug eruption in a 56 year old woman. The management of this patient
include withdrawn the offending drugs, intravenous dexamethasone.
Topical corticosteroids as a dexosimethasone 0.025% ointment and
hydrocortisone 2.5% cream , have given a satisfying result.
Keywords: erythroderma, allergic drug, dexamethasone iv,
hydrocortisone 2.5% cream, desoximethasone 0.25% ointment




















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Asrawati Sofyan Erythroderma Caused Drug Allergies

INTRODUCTION
Erythroderma is a skin disorder
that belongs to a group papulosquamous
eruption, characterized by erythema and
squama which extends more than 90%
body surface area.
(1-4)
Another name for
this disease is exfoliative dermatitis, pityri-
asis rubra (Hebra), erythroderma ( Wilson-
Brocq), and erythema scarlatiniform.
1.5

Erythroderma can be caused by the
expansion of skin and systemic disease,
psoriasis 23%, spongiotic dermatitis 20%,
drug hypersensitivity reactions 15%, CTCL
(cutaneous T-cell lymphoma) or Sezary
syndrome 5% , seborrheic dermatitis
idiopathic 4%.
(4)

The incidence of erythroderma
varied, ranging from 0.9 to 71 cases per
100,000 people.
(1)
From the data of a
study from 1981 to 2000, obtained results
which men are more often affected than
females with a ratio of 2.2: 1.
( 6)
The
average age of patients with this disease
between 41-61 years old, in which children
are the exclusion criteria in this disease in
previous studies
(1).

The pathogenesis of the erythro-
derma is unclear. In general it can be said
that the pathophysiology of erythroderma
is almost the same regard-less of the
underlying disease.
(4)
In ery-throderma
turnover increased epidermal cells
(epidermal turn over), so that the transit
time required keratinocytes through the
epidermis becomes shorter. Because
rapid succession, the stratum corneum,
there are a number of components that
are normally absorbed or metabolized.
(7)

In addition, the increased circulation ery-
throderma epidermis and dermis, and vas-
cular permeability.
(8)

The presence of cytokines in
dermal infiltration can vary depending on
the basis of erythroderma disease. Mild
erythroderma showed the presence of T
helper-1 cytokines, whereas Sezary syn-
drome showed a T helper-2 cytokine by
different pathophysiological mechanisms.
(1)
Interleukin (IL) - 1, IL-2, IL-8 cellular
adhesion molecule (ICAM) - 1, tumor nec-
rosis factor and interferon gamma is a
cytokine that plays a role in erythroderma.
Increased expression of adhesion mole-
cules increased epidermal proliferation
and production of inflammatory mediators.
(7)

Erythroderma management in
general is based on the etiology of
erythroderma itself. Hospitalization, where
dermatological care available, as well as
supporting facilities and adequate labora-
tory, generally can be a treatment option
for patients with erythroderma. Erythro-
derma can be a serious medical cases
and endanger the patient, and requires
hospitalization.
(1,4,9)
This case reported a
case erythroderma caused by drug erup-
tion, in a woman, 56 years old. Patient
respond well to systemic and topical
corticosteroids.
CASE REPORTS
A woman, 56 years, came to
Bhayangkara Hospital Makassar, with
complaints of reddish spots on the entire
body experienced since 6 days ago.
Originally itching felt on both hands, 11
days ago, the patient went to Sunggu-
minasa hospital and treated with cefadro-
xil, loratadine, and desoximethasone oint-
ments. But there is no improve-ment,
itching and redness accompanied by
swelling widespread. Redness was ori-
ginally found in mouth and face and then
the rest of the body. Fine scales showed
up all over the body and extremities later.
Patient complaint pain of eye and pain
during urination .Patient complained of
nausea. No fever. History of fever 2 days
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IJDV Vol.1 No.4 2013

before entering hospital and patient took
paracetamol. Based on history, pasient
had consumption of drugs / herbs before
itching and redness raised up. History of
drug allergies and food allergies were
denied. History of suffering with the same
complaint is denied. No previous skin
disease. A family history of similar com-
plaints denied. History of diabetes and
hypertension is denied, the patient had a
history of suffering from sinusitis and polip
nasal. On physical examination found the
patient's general state of ill being, cons-
ciousness composmentis, sufficient nutri-
tion. Vital signs within normal limits.
Dermatology examination on the entire
surface of the body (generalized) is found
erythematous macular and fine scales.
And on face area is found erythematous,
squama and crusting.
From the results of laboratory tests
found a leukocytosis (28.700/l), and other
laboratory tests in normal. The results of
histopathological examination showed
psoriasiform hyperplasia epidermal, hyper-
keratosis, parakeratosis, many neutrophil
accumulation in this area, focal hypogra-
nulosis, spongiosis, papillary dermal blood
vessels dilate, containing erythrocytes.
Upper dermis contained dense infiltrates
of inflammatory lymphocytes, eosinophils,
neutrophils perivasculer. In conclusion :
chronic spongiotic dermatitis drug
eruption.
30

Asrawati Sofyan Erythroderma Caused Drug Allergies

Patients diagnosed with erythro-
derma due to drug eruption, erythroderma
d ue to psoriasis vulgaris. Based on his-
tory, physical examination and histopatho-
logical examination, the diagnosis is
established erythrodermi ec drug erup-
tions. Treatment was given with cessation
of the suspected drugs, infusion of
Ringer's lactate (20 drops per minute),
intravenous injection dexamethasone 1
ampoule (5mg/ml) per 12 hours, ranitidine
1 ampoule per 12 hours, mebhidrolin
naphadisilate 50mg twice a day. Topical
treatment desoximethasone 0.025% oint-
ment, and hydrocortisone 2.5% cream for
face area. Treatment for post-biopsy given
erythromycin 500 mg 3 times a day, and
sodium diclofenac tablet 3x1.
The second day of treatment
patient was consulted to the eyes doctor
with a diagnosed as dry eye and was
given cendo teen eye drops, patient was
also consulted to internist for chest pain.
Fourth day of treatment, itching
was obtained, and erythema and squama
reduced, treatment was continued.
Sixth day of treatment, sometimes
itchy. Erythema and skin squama greatly
reduced. Because the lesions began to
improve, dexamethasone replaced with
oral medication methylprednisolone 20 mg
per day.
Seventh day of treatment, the
patient was allowed to go home, and
results dermatology examination showed
fine scales on the body, and only minimal
erythema in the region of vertebral and
recommended for visite an outpatient clinic
Bhayangkara hospital.
Patient was diagnosed erythroder-
ma caused by drug allergies. Treatment
was continued methylprednisolone 20 mg
per day, mebhydrolin naphadisilat 2x 50
mg daily (if itchy) and topical treatment
desoximethasone ointment.
DISCUSSION
From the history and physical
examination was found erythematous and
squama on almost the entire body, which
according to the existing literature on the
presence of symptoms of an erythematous
erythroderma and squama in the whole
body or most of the body. Erythroderma
classified into two, namely, primary
erythrodermic / idiopathic (20%) the cause
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IJDV Vol.1 No.4 2013

is unknown and secondary erythroderma
(80%) with a known cause, such as the
expansion of skin disease that has been
there before, medicines, basic disorders or
other systemic diseases .
1.410.

In this case, erythroderma is
caused by an allergic reaction of medica-
tion. Prevalence of erythroderma induced
by different drugs in various populations.
In a study conducted by E. Euch D et al on
127 cases of erythroderma in Tunisia, 13
percent of the cause is obscure. Mean-
while, from the other literature mentioned
that the prevalence of drug-induced ery-
throderma is about 5 to 40 percent of all
cases of erythroderma.
10th

There are many drugs that can
cause erythroderma. From various litera-
ture mentioned that drugs that often cause
erythroderma include calcium channel
blockers, antiepileptic, antimicrobial (cep-
halosporin, goals. Penicillin, sulfonamides,
vancomycin), allopurinol, gold, lithium, qui-
nidine, cimetidine, NSAIDs and dapsone.
(1, 11.12).
Drugs most suspected as the
cause of erythroderma in these patients is
cefadroxil and did not rule out with an
unknown medication medicine names,
paracetamol and herbs. However, in order
to diagnose the type of drug suspects, one
of them to do patch test.
Squama formed in erythroderma
varied, depending on the stage of
erythroderma and underlying disease. In
erythroderma due to an allergic reaction
drugs, squamas were found to be thinner.
(13)
In this case, initially redness of the lips
and face, and then spreads throughout the
body, within a few days. Redness of the
skin is also followed by the formation of a
thin squama.
Laboratory findings in erythroder-
mic generally does not help to establish a
specific diagnosis. Abnormalities are often
found were anemia, leukocytosis with
eosinophilia, erythrocyte sedimentation
rate (ESR) increased, hypoalbuminemia,
increased levels of uric acid.
(13)
In the
case of laboratory results showed leuko-
cytosis (28.700/l).
In this case, the results of histo-
pathological examination a chronic spo-
ngiotic dermatitis because drug eruption.
In the literature it is said that a skin biopsy
of erytroderma due to drugs showed
parakeratosis, the disappearance of the
granular cell layer and psoriasiform
hyperplasia. Histopathological examination
can not distinguish with certainty the
cause of erythroderma. Biopsy specimens
of erythroderma tend to exhibit non-
specific description such as hyperkera-
tosis, parakeratosis, acanthosis and chro-
nic inflammatory infiltration. This discovery
is often covered histological of the under-
lying disease. One third of the biopsy
specimen failed to demonstrate basic
disease erythroderma diagnosis. Accurate
diagnosis of 50% established by derma-
topathologist without obvious clinical infor-
mation. Therefore, multiple biopsies re-
commended to increase the likelihood of a
histopathologic diagnosis.
1,4,14,15

Differential diagnosis of erythro-
derma due to psoriasis removed because
based on history, the rash appeared after
patients taking the drug and no family who
suffered the same skin diseases . This is
contrast with psoriasis have a genetic
predisposition.
(1)
Erythrodermic psoriasis
begins with a typical psoriatic plaque on
the area of predilection of psoriasis. In the
clinical picture of this case showed fine
scale , in psoriasis scales are thick and
layered.
(1.13)

Apart from various causes, erythro-
derma treatment should be performed in a
hospital. The principle of treatment is to
32


Asrawati Sofyan Erythroderma Caused Drug Allergies

keep the skin moist, avoid scratching,
avoiding trigger factors, providing topical
steroids, treat basic of disease, and deal
with complications that arise. That need to
be monitored are the nutrients, protein and
electrolyte balance, circulatory status, and
body temperature.
(2.7)

In erythroderma due to allergic
drug eruption is most important to stop
the drugs suspected to be the cause of
erythroderma as soon as possible and
avoid unnecessary medication.
(8.14)

In this case, patient was hospitali-
zed and withdrawn the suspected drugs.
Control of fluid and electrolytes balances.
For prevention of infections after biopsy
was given erythromycin 1500 mg daily in
three divided doses.
In erythroderma, oral sedative anti-
histamines can help reduce pruritus ex-
perienced by patients.
(14)
In case, the
patient is given mebhidrolin napadisilate
50 mg twice daily.
In erythroderma due to allergic
drug eruption, required systemic corticos-
teroids. The dosage was given is 1-2 mg /
kg per day.
(1)
In the case of patients
treated with dexametasone 1 ampoule / 12
hours intravenously, and on the sixth day
was replaced with methylprednisolone 20
mg.
Prognosis in erythroderma de-
pends on the basis of existing disease.
Erythroderma caused by allergic drug
eruptions have relatively better prognosis,
when the suspected drug is known and its
use discontinued.
(7)
In cases patient
experienced allergic reactions caused by
drugs. Once known suspected drug of
causing the emergence of drug eruption
and dismissed. Where to find patients
respond well to treatment and could be
argued that in this case of erythrodermic
patient had a good prognosis.
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