What Is Erythrodermic Psoriasis

Erythrodermic psoriasis is a lifelong condition without a current cure, however, it can be 

very well controlled with appropriate treatment.¹ It is the least common type of psoriasis and covers the entire body with a scaly rash that can itch or burn intensely.  Erythrodermic psoriasis may be triggered by corticosteroids or other medications, severe sunburn, or another type of psoriasis.⁴

Erythrodermic psoriasis is a severe and rare skin condition that causes a red rash to form over most of your body. The rash resembles a burn and can be as fatal as one, causing chills, fever, and dehydration. Thus, erythrodermic psoriasis requires immediate medical attention.¹

Approximately 1 in 3 people who develop erythrodermic psoriasis already have plaque psoriasis. Psoriasis is an autoimmune disease that causes the immune system to be inappropriately overly active and causing harm to your own body.¹

Overview

Erythroderma is a generalised redness of the skin. It is a severe and potentially life-threatening inflammation of most of the body’s skin surface. Erythroderma can also be referred to as exfoliative dermatitis.⁶

It may be caused by a reaction to a medicine or by another skin condition or cancer. It causes redness and scaling of the skin spread over an area. This starts in patches and spreads over the body causing the skin to peel off. This leads to problems with your ability to manage body temperature and metabolic rate.  It usually results in protein and fluid loss. It  can also cause an increased metabolic rate. Erythroderma can be life-threatening and you may need to spend time in the hospital or burn center for treatment.⁶

When erythroderma is caused by psoriasis it will then be referred to as erythroderma psoriasis. One third of people who develop erythrodermic psoriasis already have plaque psoriasis. Thus, having another type of psoriasis is a risk factor for erythrodermic psoriasis.¹ Psoriasis is a chronic inflammatory skin condition affecting roughly 2% of the population. Erythrodermic psoriasis (EP) is a rare and severe variant of the disease, with an estimated prevalence among psoriatic patients ranging from 1%–2.25%.⁵

Psoriasis is an autoimmune disease that causes your immune system to be inappropriately overly active causing harm to your own body. Inflammation from this reaction causes new skin cells to form too fast.¹

Inflammation caused by psoriasis can impact other organs and tissues in the body. People with psoriasis may also experience other health conditions. One in three people with psoriasis may also develop psoriatic arthritis.⁷

Psoriasis can appear anywhere on the body. It can appear on the eyelids, ears, lips, skin folds, hands, feet, scalp and nails. Plaques can be a few small patches or can affect large areas. You can have psoriasis plaques and scales in more than one location on the body at a time.⁷

People with poorly controlled plaque psoriasis are most at risk for developing erythrodermic psoriasis. Thus, abruptly stopping psoriasis treatments, like corticosteroids or immunosuppressants, can cause erythrodermic psoriasis. Overusing medications like topical steroids or retinoids (a vitamin A-related drug) can also cause symptoms.¹ Erythrodermic psoriasis is the least common type of psoriasis, and can cover the entire body with a peeling rash that can itch or burn intensely.⁸

According to Mayo Clinic there are other several types of psoriasis, each of which varies in its signs and symptoms:

• Plaque psoriasis is the most common type of psoriasis. Plaque psoriasis usually appears on the elbows, knees, lower back and scalp and the patches vary in color. Signs and symptoms of plaque psoriasis usually include dry, itchy, raised skin patches (plaques) covered with scales⁸
• Nail psoriasis can affect fingernails and toenails, causing pitting, abnormal nail growth and discoloration. Psoriatic nails might loosen and separate from the nail bed (onycholysis). Severe disease may cause the nail to crumble⁸
• Guttate psoriasis primarily affects young adults and children. Guttate psoriasis is usually triggered by a bacterial infection such as strep throat. Guttate psoriasis is marked by small, drop-shaped, scaling spots on the trunk, arms or legs⁸
• Inverse psoriasis mainly affects the skin folds of the groin, buttocks and breasts. Inverse psoriasis causes smooth patches of inflamed skin that worsen with friction and sweating. Fungal infections may trigger this type of psoriasis⁸
• Pustular psoriasis is a rare type, causing clearly defined pus-filled blisters⁸

Causes of erythrodermic psoriasis

Triggers of erythrodermic psoriasis include:²

• Allergic reaction to a medicine that causes a rash or other skin symptoms
• Certain medicines, such as systemic steroids, lithium, antimalarials, and interleukin II³
• Starting or stopping medicines e.g. Withdrawal of oral corticosteroids (prednisone) or withdrawal of excessive use of strong topical corticosteroids³
• Infections/severe illness
• Cancer
• Psoriasis
• Severe sunburn
• Stress
• Excessive alcohol use or substance use disorder
• Low calcium
• Strong coal tar preparations³

Signs and symptoms of erythrodermic psoriasis

Signs and symptoms include redness and inflammation that resembles a severe burn or sunburn on more than 90% of your body. The skin rash is very itchy and may cause a burning sensation. You may also develop peeling skin that comes off in large sheets. Some people lose fingernails and toenails too.¹

Other patients can have systemic symptoms of fever, tachycardia, fatigue, malaise, chills, dehydration, lymphadenopathy, arthralgia, myalgia, insomnia, sweats, diarrhea, constipation, weight changes, allodynia, and rarely high output heart failure (due to excessive water loss and edema) and cachexia. Laboratory results may show massive protein and fluid loss, leukocytosis, anemia, elevated C-reactive protein and erythrocyte sedimentation rate, electrolyte abnormalities, temperature irregularities (hypothermia or hyperthermia), and rarely abnormal liver function tests.⁵

Erythrodermic psoriasis can come on suddenly (an acute rash) in a couple of days. More commonly, plaques expand from a pre-existing psoriasis rash. Sometimes full development of erythrodermic psoriasis may occur gradually over a few months. Erythrodermic psoriasis symptoms can come and go or can be put in remission meaning no rash for some time,  if it is well managed or treated, however flare-ups can occur with the diffuse rash and symptoms returning.¹

Complications include:³

• Dehydration
• Heart failure
• Infection
• Hypothermia
• Protein loss and malnutrition
• Oedema (swelling), particularly of lower legs
• Death

Management and treatment for erythrodermic psoriasis

Erythrodermic psoriasis is a lifelong condition without a current cure, however, treatments can minimise and prevent symptoms.¹ A severe flare-up requires immediate medical attention. 

Erythrodermic psoriasis treatments include:

• Hypoallergenic moisturisers and cool compresses
• Topical ointments like corticosteroids or retinoids
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Immunosuppressants like cyclosporine or methotrexate
• Disease-modifying antirheumatic drugs (DMARDs)
• Oral retinoids
• Biologic therapies¹

Management of erythrodermic psoriasis can be difficult however it includes:

• Hospitalisation for supportive care including intravenous fluids and temperature regulation
• Bland emollients and cooling wet dressings
• Bed rest
• Treatment of complications (for example antibiotics, diuretics (water tablets), nutritional support)
• Low-dose methotrexate, ciclosporin or acitretin
• Individual cases have been reported to have successful outcomes with biologic agents, including the TNF-alpha inhibitors adalimumab, etanercept and infliximab, the IL12/23 inhibitor, ustekinumab, and IL17 inhibitor bimekizumab

Oral corticosteroids should be avoided if possible because withdrawal risks worsening the erythrodermic state and may cause generalised pustular psoriasis. However, sometimes they are the only treatment that helps.³ Topical tar preparations and phototherapy should also be avoided in the early treatment of erythrodermic psoriasis as they may worsen the condition.³

FAQs

How is erythrodermic psoriasis diagnosed

A dermatologist diagnoses and treats skin diseases like psoriasis. Your healthcare provider may diagnose the condition based on a previous history of psoriasis, as well as your symptoms. You may get a skin biopsy to confirm the diagnosis.¹

How can I prevent erythrodermic psoriasis

Keeping plaque psoriasis under control with treatments is the best way to prevent erythrodermic psoriasis.

If you develop erythrodermic psoriasis,  to prevent a flare-up you should:

• Cut back on alcohol
• Find healthy ways to cope with stress
• Protect your skin against sun damage
• Seek help to quit smoking
• See your dermatologist regularly¹

Is erythrodermic psoriasis contagious

Psoriasis is not contagious thus, you cannot catch psoriasis from another person. Usually, something triggers psoriasis, causing symptoms to appear or worsen and  these triggers vary from person to person.⁷

Who are at risk of erythrodermic psoriasis

People with cancer and other skin conditions including psoriasis are at risk of developing erythrodermic psoriasis. Symptoms often start between ages 15 and 25, but can start at any age. Men, women, and children of all skin colours can get psoriasis.⁷

How common is erythrodermic psoriasis

Erythrodermic psoriasis (EP) is a rare and severe variant of psoriasis vulgaris, with an estimated prevalence of 1%–2.25% among psoriatic patients.⁵ Psoriasis affects an estimated 3% of Americans, mostly adults. As many as 9 in 10 people with psoriasis have plaque psoriasis. The erythrodermic type is uncommon, occurring in about 3% of people who have psoriasis.¹

When should I see a doctor

Call your healthcare provider if you experience a flare-up or have signs of:

• Dehydration
• Excessive peeling of the skin
• Infection, including fever or chills
• Severely itchy or painful skin¹
• Severe redness/discoloration and shedding of skin over a large area of the body
• Exfoliation often occurs in large "sheets" instead of smaller scales
• Skin looks as if it has been burned
• Heart rate increases
• Severe itching and pain
• Body temperature goes up and down, especially on very hot or cold days²

Summary

Erythrodermic psoriasis is a chronic condition without a current cure however it can be 

very well controlled with an appropriate treatment.¹ It is the least common type of psoriasis and covers the entire body with a scaly rash that can itch, stingy, or burn intensely. Risk factors include having another type of psoriasis, severe illness, cancer, severe sunburn, and excessive substance use eg alcohol. It may also be triggered by corticosteroids or other medications. Treatment of erythrodermic psoriasis usually requires prescription oral medication, medicated wet dressings, and topical steroids. For severe diseases, you might need a combination of therapies and hospital care.⁴