Erythrodermic psoriasis

Erythrodermic [eh-REETH-ro-der-mik] psoriasis is a particularly inflammatory form of psoriasis that often affects most of the body surface. It may occur in association with von Zumbusch pustular psoriasis. It is a rare type of psoriasis, occurring once or more during the lifetime of 3 percent of people who have psoriasis. It generally appears on people who have unstable plaque psoriasis. This means the lesions are not clearly defined. Widespread, fiery redness and exfoliation of the skin characterize this form. Severe itching and pain often accompanies it.

Individuals having an erythrodermic psoriasis flare should see a doctor immediately. This form of psoriasis can be life-threatening.

Symptoms

• Severe redness 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 days

Erythrodermic psoriasis “throws off” the body’s chemistry. This causes protein and fluid loss that can lead to severe illness. Edema (swelling from fluid retention), especially around the ankles, may develop, along with infection. The body may not be able to maintain its temperature. This can produce shivering episodes. Erythrodermic psoriasis also can bring on pneumonia and congestive heart failure. People with severe cases often require hospitalization. Erythrodermic psoriasis can occur abruptly at the first signs of psoriasis or it can come on gradually in people with plaque psoriasis. The reason erythrodermic psoriasis appears is not understood. However, there are some known triggers.

Triggers

• Abrupt withdrawal of systemic treatment
• Severe sunburn
• Allergic, drug-induced rash that brings on the Koebner phenomenon (a tendency for psoriasis to appear on the site of skin injuries)
• Use of systemic steroids (cortisone)
• Infection
• Emotional stress
• Alcoholism

Treatment

Initial treatment usually includes medium-potency topical steroids and moisturizers combined with wet dressings, oatmeal baths and bed rest. You also may be prescribed antibiotics. It is important to restore and maintain fluids in the body. Other treatments include:

• Systemic medications are most effective and usually are required to bring severe cases under control. These include methotrexate, acitretin (brand name Soriatane) or cyclosporine. Use of systemic steroids for erythrodermic psoriasis is controversial. If used, taper off them slowly. Stopping steroids suddenly can trigger a flare of psoriasis.
• TNF-alpha blocking biologics such as Enbrel (etanercept), Humira (adalimumab), Remicade (infliximab) and Simponi (golimumab) target a type of immune cell called a T-cell that specifically cause inflammation in psoriasis and psoriatic arthritis. Such medications can be used as effective treatment for erythrodermic psoriasis.
• Combination treatments are frequently required, meaning using topical products and one or two systemic medications. Health care providers usually do not prescribe UVB (ultraviolet light B) or PUVA (the light-sensitizing drug psoralen plus ultraviolet light A) treatment until the redness of the skin has gone down.

Once the erythrodermic psoriasis flare passes, the psoriasis usually reverts to the way it looked before the flare. Some health care providers may prescribe pain medications, as this is an especially painful condition. Medication for itch, anxiety or sleep may also be prescribed if appropriate.