Synopsis
Recognise erythroderma across skin tones, stabilise barrier, temperature and circulation, identify infection or organ failure, and investigate psoriasis, eczema, medicines, pityriasis rubra pilaris and cutaneous lymphoma without delaying supportive care.
- Erythroderma means erythema and scale affecting more than 90% of body surface area; it is a dangerous clinical state, not a final aetiological diagnosis.
- In brown or black skin, erythema may appear violaceous, grey, dusky or mainly as warmth, oedema and altered texture; examine palms, soles, nails, scalp and mucosae in good light.
- Barrier loss causes evaporative fluid and heat loss, protein loss, increased metabolism, cutaneous vasodilation and infection risk; apparently hot skin can coexist with a cold patient.
- Common causes include eczema, psoriasis and medicines; pityriasis rubra pilaris, cutaneous T-cell lymphoma, pemphigus foliaceus, severe scabies and congenital disorders are important alternatives.
- Establish the timeline before labels disappear: previous plaque distribution, islands of sparing, palmoplantar change, nail disease, severe itch, lymph nodes and every new or stopped medicine can discriminate.
- Discuss urgently with dermatology; admit anyone physiologically compromised and have a low threshold for frailty, cardiac or renal disease, very rapid onset or unreliable home support.
- Stabilisation uses a warm environment, gentle handling, bland greasy emollient, non-adherent care, nutrition and measured replacement guided by observations, weight, urine and electrolytes.
- Stop plausible non-essential culprit medicines after a risk assessment, but do not abruptly withdraw long-term systemic corticosteroid or another essential drug without a safe alternative.
- One biopsy can be non-specific because the final common inflammatory pattern obscures the cause; select active sites and repeat clinicopathological assessment when disease persists.
- Avoid reflex systemic corticosteroid treatment of undifferentiated erythroderma, particularly possible psoriasis, because withdrawal can provoke rebound or pustular crisis.
Key red flags
Core hypothermia, tachycardia, hypotension, oliguria, rapid oedema or weight gain, breathlessness, chest pain, confusion, painful erosions, pustulation, mucosal disease, fever, focal infection, abrupt medicine withdrawal or frailty requires emergency hospital assessment.
Fever, severe tenderness, honey crust, purulence, monomorphic erosions, pustules, blisters, mucosal lesions, focal necrosis or crepitus indicates a superimposed or alternative emergency.
Investigation priorities
Detect thermoregulatory, circulatory, respiratory and renal failure immediately.
Management branches
Erythroderma is suspected, especially with systemic symptoms or frailty.
- Measure extent and full observations including core temperature, perfusion, weight and urine, then involve acute medicine and the on-call dermatologist.
- Admit physiological compromise or high risk, use a warm humidified environment, gentle handling, non-adherent linen and regular bland ointment.
- Replace fluid, electrolytes and nutrition cautiously against repeated urine, weight, renal, albumin, respiratory and cardiac findings rather than a fixed volume.
- Culture suspected infection and treat sepsis promptly while providing thrombosis, pressure-area, eye and temperature protection appropriate to immobility and skin loss.
Key medicines
Bland paraffin-based emollient ointmentApply generously to all dry intact skin every 2 to 4 hours and immediately after gentle washing, with quantities adjusted to surface area and exudation.Paraffin-soaked clothing, bedding and dressings ignite readily even after washing; avoid flames and smoking, do not use a slippery bath unsupervised, and avoid application onto infected exudate without review.
Hydrocortisone 1% ointmentApply a thin measured layer once or twice daily for 5 to 7 days to selected face or flexural inflammation, then reassess with dermatology.Do not use as sole therapy for HSV, fungal or bacterial infection; widespread barrier failure increases systemic absorption, and periocular exposure, atrophy and diagnostic masking require careful site and duration control.