Indian Journal of Paediatric Dermatology

ORIGINAL ARTICLE
Year
: 2013  |  Volume : 14  |  Issue : 1  |  Page : 9--12

Erythroderma in children: Clinico-etiological study from Punjab


Jyotika Kalsy, K J P S Puri 
 Department of Dermatology, Venereology and Leprosy, Government Medical College, Amritsar, Punjab, India

Correspondence Address:
Jyotika Kalsy
129, A Race Course Road, Opposite Beams Hospital, Amritsar - 143 001, Punjab
India

Abstract

Background: Erythroderma is generalized inflammatory disorder of skin manifesting with erythema and scaling affecting more than 90% of skin surface. The causes vary from place to place. It is important to establish the underlying cause wherever possible for proper management. Aim: The aim of this clinical study is to find out the etiological causes in the pediatric age group, i.e., 0-15 years. Materials and Methods: A total of 14 erythroderma patients of both sexes were included into the study between August 2008 and July 2010. Detailed history, general physical examination, mucocutaneous examinations and investigations were performed and recorded. Results: Out of 14 cases, 10 (71.4%) were boys and 4 (28.6%) were girls. Age range was between 1.5 years and 14 years. The most important cause of erythroderma in our study was found to be drugs especially for epilepsy followed by atopic eczema, psoriasis, ichthyosis and crusted scabies. Conclusion: Erythroderma in children although rare requires urgent attention as it can become life threatening if mismanaged and misdiagnosed. In our study, drugs turned out to be the most common cause so drugs should be given to minimum in children as far as possible.



How to cite this article:
Kalsy J, Puri K. Erythroderma in children: Clinico-etiological study from Punjab.Indian J Paediatr Dermatol 2013;14:9-12


How to cite this URL:
Kalsy J, Puri K. Erythroderma in children: Clinico-etiological study from Punjab. Indian J Paediatr Dermatol [serial online] 2013 [cited 2019 Oct 16 ];14:9-12
Available from: http://www.ijpd.in/text.asp?2013/14/1/9/116841


Full Text

 Introduction



Erythroderma is a generalized inflammatory disorder of the skin manifesting with erythema and scaling affecting more than 90% of the skin surface. Primary erythroderma arises on normal looking skin due to the underlying systemic disorder or because of a drug reaction while the secondary erythroderma arises from a pre-existing dermatoses. [1]

In erythroderma, there is an increase in the rate of epidermal cell turnover. The transit of the cells through the epidermis is shortened. Hence, a greater amount of cell components is lost from the skin surface in the form of scales. Approximately, 20-30 g of scales per day is the loss. The amount of protein loss is so large that the systemic metabolism is affected. [2]

Hence, it is important to prevent erythroderma in children.

 Materials and Methods



A retrospective clinico-etiological study was carried out. Any child in erythroderma reporting to the dermatology out-patient department between August 2008 and July 2010 was investigated. A detailed history, general physical examination, mucocutaneous examination was carried out. Following investigations were done:

Complete hemogram with erythrocyte sedimentation rate with absolute eosinophil count and immunoglobulin E (IgE) levels, urine complete examination, skin and mucosal swabs for any infection, kidney function tests with serum electrolytes, liver function tests with the serum proteins, Microscopy for fungus and scabies, Fine needle aspiration cytology of enlarged lymph nodes, human-immuno deficiency virus (HIV) antibody testing, serum markers for viral hepatitis, X-ray chest, ultrasound abdomen, skin biopsy.

 Results



A total of 14 children with erythroderma were included in the study out of total 12,464 children making incidence of 0.11%. Male:female ratio was 2.5:1. Acute onset of the disease was seen in 43% of the cases while 57% had chronic course of the disease.

The main presenting complaint was itching in 36% of the children.

On general physical examination, fever and tachycardia was seen in 65% of the cases, facial edema in 6% and pedal edema in 10% and lymphadenopathy in 18% of the cases.

On mucocutaneous examination, all patients had scaling and erythema. Nail involvement in the form of shiny smooth nails and pitting was seen in 20% of cases and diffuse hair loss in 4% of the cases.

Laboratory investigations: Showed mild anemia, hypoalbuminemia, electrolyte imbalance was seen in 40% of the cases of mild degree. It was not significant as it was corrected by supportive therapy.

There was one case of crusted scabies, which turned out to be HIV reactive after investigation.

Histopathology was performed in all the cases which showed spongiotic psoriasiform dermatitis in 9 (64.3%) cases, lichenoid drug eruption in 5 (35.7%) cases.

Etiologically drugs showed the highest incidence 6 (42.8%) followed by psoriasis, Icthyosis 5 (35.7%), atopic eczema 2 (14.3%) and 1 (7.1) case of crusted scabies.

Final diagnosis was made after considering all the parameters such as clinical, biochemical, histological and evolution of erythroderma in each patient.

 Discussion



Erythroderma was first described by Hebra in 1868 as a reaction pattern characterized by generalized erythema with scaling affecting more than 90% body surface. It is usually accompanied by systemic manifestations including some metabolic changes. [3]

Erythroderma is as a result of many different causes and represents extreme state of skin irritation involving whole or most of the skin surface. It implies an important risk to the life of the patient. [4]

The clinical features of erythroderma are non-specific. Sometimes there is a long delay in reaching the diagnosis after the erythroderma clears after several months and the characteristic lesions can be observed. Certain clues like scaling and pruritus could not be related to any specific cause. Erythroderma of long duration may cause hair loss or nail dystrophy regardless of its origin, so these changes are non-specific. In erythrodermic patients, clinico pathological correlation is usually poor due to the non-specific changes induced by the inflammatory process of erythroderma. [4]

In our retrospective study of erythroderma in children, we found incidence of 0.11%, which is the same as in the study conducted at New Delhi. [5] Male preponderance is seen in our study, which is same as in other studies of adult patients [6] and also in 1-15 years of age group. [7]

Acute onset of the disease is seen in 43% of the patients and 57% had chronic course, which is in accordance with other study of erythroderma in children. [7]

Etiologically drugs showed the highest incidence 6 cases (42.8%). Relationship between drugs and erythroderma was made from the history of taking of drugs prior to the skin presentation which progressed rapidly to involve the whole body. These cases showed improvement after the withdrawal of drugs and with treatment. Drugs were mainly taken for epilepsy, fever and sore throat in our study. They were phenobarbitone, phenytoin, co-trimoxazole. These patients might be having sensitivity to these drugs or these drugs are prescribed more in prescriptions. Similarly, higher incidence of sensitivity of other drugs in children is seen in other studies. [8],[9]

Disorder of keratinization was seen in 5 cases (35.7%). 3 (60%) cases belonged to non-bullous icthyosiform erythroderma and 2 (40%) cases of psoriasis. In these cases, there was previous history of similar skin problem. They were put on methotrexate and showed gradual improvement. These cases are seen in more number as complicated cases are referred from different centers for treatment to our tertiary care center [Figure 1] and [Figure 2].{Figure 1}{Figure 2}

Atopic eczema was seen in 2 cases (14.3%). In these cases, there was a history of papules and vesicles over cheeks since childhood. Lichenification was seen especially over cubital and popliteal fossae. There was history of intolerance to wool and certain food items (peanuts and eggs) were present. The history of nasobronchial allergy was present in the family of one of the child. Nails were smooth and shiny. On investigations, serum IgE levels were markedly raised. This is same as in other study of erythroderma in children [7] [Figure 3].{Figure 3}

One interesting case of 11-year-old child in erythroderma came for treatment. He was admitted and investigated. The child was having hyperkeratotic, crusted lesions especially over palms, soles; lumbosacral region, ear helix and few nodular lesions over scrotum were present. He was having a complaint of itching and a similar problem of itching was also present in the other family members. He belonged to lower socio-economic status. On investigations, microscopy for scabies showed mite and the child turned out to be HIV reactive in laboratory tests. Immunodeficiency was the leading cause of erythroderma in a study done in 2000. [10]

Childhood erythroderma though rare and studied less is important from the mortality point of view. Prognosis depends upon the primary cause of erythroderma. All the cases are to be managed as in-patients for supportive therapy and treatment of hematologic, biochemical and metabolic imbalance if any, prevention and treatment of infection, monitoring of vital signs and topical application of emollients. Correct diagnosis is important to prevent treating the condition, wrongly by topical steroids by indigenous practitioners.

 Conclusion



Since this study showed drugs to be the main cause, so we recommend that

One should suspect drugs as an important cause whenever a child comes in erythrodermaSelf-medication and indiscriminate use of drugs by parents should be avoided.

Above measures will help to prevent these cases from being mismanaged and misdiagnosed.

References

1Wong KS, Wong SN, Tham SN, Giam YC. Generalised exfoliative dermatitis: A clinical study of 108 patients. Ann Acad Med Singapore 1988;17:520-3.
2Shuster S, Wilkinson P. Protein metabolism in exfoliative dermatitis and erythroderma. Br J Dermatol 1963;75:344-53.
3Prakash BV, Sirisha NL, Satyanarayana VV, Sridevi L, Ramachandra BV. Aetiopathological and clinical study of erythroderma. J Indian Med Assoc 2009;107:100, 102-3.
4Botella-Estrada R, Sanmartín O, Oliver V, Febrer I, Aliaga A. Erythroderma. A clinicopathological study of 56 cases. Arch Dermatol 1994;130:1503-7.
5Sarkar R, Garg VK. Erythroderma in children. Indian J Dermatol Venereol Leprol 2010;76:341-7.
6Bharatiya PR, Joshi PB. Study of exfoliative dermatitis. Indian J Dermatol Venereol Leprol 1995;61:81-3.
7Sarkar R, Sharma RC, Koranne RV, Sardana K. Erythroderma in children: A clinico-etiological study. J Dermatol 1999;26:507-11.
8Pal S, Haroon TS. Erythroderma: A clinico-etiologic study of 90 cases. Int J Dermatol 1998;37:104-7.
9Wilson DC, Jester JD, King LE Jr. Erythroderma and exfoliative dermatitis. Clin Dermatol 1993;11:67-72.
10Pruszkowski A, Bodemer C, Fraitag S, Teillac-Hamel D, Amoric JC, de Prost Y. Neonatal and infantile erythrodermas: A retrospective study of 51 patients. Arch Dermatol 2000;136:875-80.