Exfoliative Dermatitis

Presented by: Henry Foong FRCP,

Ipoh, Malaysia,

July 5th, 2001

History:
M.S. is a 39-year-old Indian male who presents for evaluation and treatment of a generalised scaling and erythema. He first noted patches of scaling and erythema on the elbows and knees 2 years ago. This subsequently spread to the scalp, face, trunk and extremities. He is unemployed at the moment but has done odd labour jobs. M.S. is the eldest of 5 siblings. His younger brother has similar problems on the trunk and legs but to a lesser extent. The patient is married and has 6 children.

Examination:
Generalised dry scaly lesions on scalp, face, trunk and extremities. The lesions were generally dark plate-like scales all over. Severe diffuse alopecia was noted on the scalp. Nails were long and dystrophic.

     

Lab:
None

Histopath:
None

Presumptive Diagnosis:
Exfoliative Dermatitis

Comments:
Dr. Elpern's Comments:
I have seen cases of exfoliative erythroderma which looked like this and actinic reticuloid (but the latter only in older individuals) and also patients with hyper IgE syndrome. The alopecia is strange. This is a worrisome case and I think he may need more history and some lab studies - These would include cbc, chemistries, poss HIV serology. Can the patient afford the lab studies?

My advice would be to sit down with him and spend more time on the history before committing him to the expense of costly lab studies - you may have a clearer idea of what is going on then. Such as - is there a history of atopy or preexisting skin disease. Please give us follow-up - David Elpern

Follow Up (7/18/01):
Due to financial constraints, I have advised the patient to be admitted to the general hospital for further evaluation and treatment. Work up for the patient was unremarkable with a normal FBC, blood biochemistry, and CXR. VDRL/TPHA negative. Skin biopsy of the lesion showed features consistent with psoriasis: acanthosis with hyperkeratosis and parakeratosis. Acanthotic epithelium shows bulbous elongation of rete ridges. Upper dermal lymphohistiocytic infiltrate were noted.

He was managed conservatively with moisturisers, topical betnovate ointment and lesions cleared after 2 weeks in the ward.

Final Diagnosis: Erythrodermic psoriasis

The patient had subsequently left for Singapore to look for a better job and had not returned for follow up.

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