Photo Rounds

Red, peeling skin

A 64-year-old woman went to her family physician (FP) because she had red peeling skin and hadn’t been feeling well for the past week. Her husband had driven her and said his wife had been complaining of chills and weakness for 2 days. Physical examination revealed the patient’s skin was red from her scalp to her feet. She was also hypotensive and tachycardic, had dry eyes, and a dry mouth. The patient had no history of skin problems. She was admitted to the hospital for rehydration, diagnosis, and treatment.

What’s your diagnosis?


The FP diagnosed erythroderma, which can be life-threatening because of dehydration. The severe exfoliation (sheets of skin peeling off) impairs the skin’s barrier function, which leads to dehydration and makes the patient susceptible to infection. (This is similar to a patient with second-degree burns.)

At the hospital, the patient received supportive therapy with intravenous fluids and urine and blood cultures to check for infections. A Foley catheter was inserted to measure urine output. A dermatology colleague was available for consultation and performed a 4-mm punch biopsy to determine the etiology of the erythroderma, and a dermatopathologist was called.

The following labs were ordered in anticipation of cyclosporine therapy: complete blood count, chemistry panel, uric acid, magnesium level, QuantiFERON TB gold, hepatitis C antibody, and hepatitis B surface antigen, surface antibody, and core antibody.

The FP prescribed 0.1% triamcinolone ointment using the wet pajama technique: the ointment is applied over the red areas and then covered with wet hospital gowns overnight. The cloth is made wet with lukewarm water and wrung out so that it is not dripping with water. A dry blanket is applied over the wet layer of clothing. The patient then attempts to sleep in this and only removes it if she becomes chilled or is unable to sleep at all.

Results of the punch biopsy were consistent with erythrodermic psoriasis. The patient did not have a history of renal disease or hypertension, and lab tests returned sufficiently normal, so cyclosporine was not contraindicated. Oral cyclosporine was started while the patient was in the hospital. She recovered rapidly and was discharged with ongoing cyclosporine treatment and topical steroids. The patient followed up with the dermatologist for treatment.

Photo courtesy of Jack Resneck Sr, MD. Text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Henderson D. Erythroderma. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013: 915-921.

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