CASE REPORT

ERYTHRODERMA ET CAUSA PSORIASIS VULGARIS Ramona Utami1, Fitriyani Sennang1, Dirmawati Kadir1, Ni Ketut Sungowati2 1

Department of Dermatovenereology Medical Faculty of Hasanuddin University / Wahidin Sudirohusodo Hospital Makassar 2 Department of Phatology Anatomy Medical Faculty of Hasanuddin University / Wahidin Sudirohusodo Hospital Makassar

ABSTRACT Erythroderma is a skin disorder characterized by erythematous and squama which covers most of the body (more than 90% body surface area). Erythroderma called exfoliative dermatitis. Erythroderma is most often caused by spongiotic dermatitis, drug hypersensitivity reactions, cutaneous lymphoma cells, and other unknown causes (idiopathic). One case of erythroderma caused the extent of psoriasis vulgaris was reported with systemic corticosteroids and topical corticosteroids plus emollient that provides clinical improvement. Keyword : erythroderma, psoriasis vulgaris

Address for correspondence : Ramona Utami, dr., Department of Dermatovenereology Medical Faculty of Hasanuddin University / Wahidin Sudirohusodo Hospital Makassar, Blok N/134 Perdos Unhas Tamalanrea Jl. Perintis Kemerdekaan X Makassar, South Sulawesi, Indonesia 90245, [email protected]

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INTRODUCTION

and human immunodeficiency virus (HIV). (5,6,7) Diagnosis is based on history, physical examination and investigations such as histopathology. Erythroderma manage-ment in general is based on the etiology of erythroderma itself. (1-4) Erythroderma can be a serious medical cases and require hospitalization. (3,4,6) Initial treatment in the form of nutrition, correction of fluid and electrolyte imbalance, hypothermia prevention and treatment of secondary infections. (1-4)

Erythroderma is a skin disorder characterized by erythematous and squama which covers most of the body (more than 90% body surface area). Also called dermatitis exfoliative erythroderma. (1) Erythroderma can be caused by a wide variety of skin and systemic diseases. Of 18 published studies obtained results that skin disease that affects approximately plays 52% of cases of erythroderma include psoriasis (23%), spongiotic dermatitis (20%), drug hypersensitivity reactions (15%), CTCL (cutaneous T-cell lymphoma) or Sezary syndrome 5%, 4% and seborrheic dermatitis idiopathic 733%.(2) There is no precise data on the prevalence or incidence of erythroderma.(1) A study estimating the incidence of erythroderma was 0.9 per 100,000 population.(2) The incidence of erythroderma is more common among men than women, with a ratio of 2:1 - 4:1 and the average age ranged from 41- 61 years. (1,2)

Systemic corticosteroids may be considered in cases of erythrodermic and generalized pustular psoriasis.(2) This paper reported a case of erythroderma caused by psoriasis vulgaris in men aged 46 years old, treated with systemic and topical corticosteroids and emollients and provide a clinically meaningful change. CASE REPORT A man aged 46 years old, admitted to Dermatology clinic Wahidin Sudirohusodo Hospital with a complaint of skin redness and peeling on the face and almost the entire body approximately 1 month ago. Patients initially complained of reddish spots appeared on the back and arms, spread on the feet, hands and face with exfoliation. The complaint with the pain and piercing in the skin. No history of previous treatment. Patients having ever smoked more than 30 years. No complaints of joint pain. Denied a history of alcohol consumption, history of similar complaints previously denied. A history of drug allergies and food denied, history of systemic disease and similar illnesses in the family denied. On physical examination found a good general condition. Vital signs showed blood pressure 120/80 mm Hg, pulse 80x/minute, respiration rate 20x/minute and body temperature 37oC. ermatological

Pathogenesis is still unclear. However, there are known interactions of cytokines and cellular adhesion molecules, including interleukin -1 , -2 and -8, intercelluler adhesion molecule (ICAM-1) and tumor necrosis factor (TNF). Interaction that causes an increase in epidermal turnover subsequently lead to an increase in mitotic activity and the number of cells in the skin (3,4) germinativum. Psoriasis is a chronic skin disease with recurrent lesions typical form of patches demarcated erythema, covered by thick layers skuama shiny white. (5) The cause of psoriasis has not been clear until now, thought to many factors that play a role in psoriasis, among others , genetic factors, environmental, trauma, infections, drugs, sunlight, metabolic, psychological, alcohol, smoking 45

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status examination showed in almost the entire surface of the body (generalized) found a macular erythematous, fine scales, and xerosis (Fig. 1a-d). Routine blood laboratory tests, kidney function and liver function within normal limits. Based on history and physical examination, this

case differential diagnosis with erythrodermic et causa psoriasis, erythrodermic et causa seborrheic dermatitis, erythrodermic et causa atopic dermatitis. To established the diagnosis skin histopathology examination was done. 46

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Management of this patient got systemic therapy oral methylprednisolone 12 mg twice a day in morning and afternoon, erythromycin 500 mg three times a day. B1, B6 and B12 vitamins were given once a day. Topical therapy 2.5% hydrocortisone cream (applied on face), clobetasol propionate cream plus lanolin 10% plus vaseline smeared onto the upper half of the body in the morning and half lower body in the afternoon.

Erythroderma due to the expansion of the skin disease most often caused by psoriasis and seborrheic dermatitis. (1,2) In this case erythroderma caused by psoriasis vulgaris. Erythroderma is a disease that is relatively common in tropical countries. The incidence of erythroderma is more common among men than women, with a ratio of 2:1-4:1 and the average age ranged from 41-61 years. (1,2) The patient was a 46 years old male.

Histopathologic examination showed a picture of the epidermis with psoriasiform hyperplasia, mild spongiosis, hyperkeratosis, focal parakeratosis, focal hypogranulosis, suprapapilary plate thinning, there are 1-2 neutrophils in the area parakeratosis, dilated blood vessels papillary dermis contains erythrocytes and there perivasculer lymphocytic inflammation infiltrates. The conclusion was erythrodermic et causa psoriasis vulgaris (Fig. 2a and b) On the control day 7, patient complaints of itching and burning sensation. Dermatologic examination showed redness was reduced and squama thinning. Treatment methylprednisolone 8 mg dose twice a day, cetirizine 10 mg once a day at night. Topical therapy given lanolin 10%, salicylic acid 3% plus desoximethasone plus vaseline on the body (except the face and neck) in the morning and afternoon.

Psoriasis is a chronic inflammatory skin diseases with recurrent lesions typical form of patches demarcated erythema, covered by thick layers squama white shiny like mica, with candles droplet phenomenon, koebner phenomenon and Auspitz signs . (1,2,5,6,9-12) According to Henseler and Christopers, there are two forms of the type I psoriasis with onset before age 40 years and is associated with human leucocyte antigen (HLA), and type II with onset after the age of 40 years and little relation to HLA. (2,6) Our case patient aged 46 years old and no history of similar illness in the family. Based on histopathological exa-mination obtained a description of the epidermis with psoriasiform hyperplasia, mild spongiosis, hyperkeratosis, focal parakeratosis, focal hipogranulosis, suprapapilary plate thinning, there are 1-2 neutrophils in the area parakeratosis, dilated blood vessels papillary dermis contains erythrocytes and there perivascular lymphocytic inflammation infiltrates. The conclusion is erythrodermic et causa psoriasis vulgaris can be considered. In the literature mentioned histopathological picture of psoriasis vulgaris varies, depending on the stage of the lesion. Histopathological picture in this case including the earlystage lesions. (12)

DISCUSSION This case established the diagnosis of erythroderma based on history, physical examination and histopathological examination. (2) In the history and physical examination were obtained erythematous and squama on almost the entire body. Literature said that symptoms of erythroderma such as erythema and squama on the whole body or most of the body. (1,2,4,6,8,9) Erythroderma can be caused by skin and systemic diseases. (2) 47

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Primary management of erythroderma, whatever the cause, is water and electrolyte correction. (1-3,6,9,12) Local skin care gently, including the use of oatmeal baths and wet dressings to crusting lesion, emollients and corticosteroids should be given. Symptomatic therapies include antihistamines sedatives for pruritus. (1,2) Systemic antibiotics required for patients with systemic secondary infections. Patients in the absence of secondary infection may also require systemic antibiotic therapy as the colonization of bacteria which can cause exacerbation of erythroderma. Appropriate literature, the patient treated with oral antibiotics, cetirizine (anti-histamine), topical corticosteroids, emollients (lanolin and petroleum jelly) which serves to hold the water evaporation from the skin. (1,2,7,11)

Prognosis depends on the cause. Erythroderma prevention can be done by avoiding the administration of drugs that can lead to erythroderma. Medical records of patients known to have allergies, as well as the discontinuation of systemic steroids in patients with psoriasis and preventing rebound flare. (2) After the lesion got clinical improvement , the patient should be given the understanding of the basic causes of erythroderma disease. (1) It is also clear that psoriasis is a chronic disease is genetic, and can not promise complete recovery and should refrain from any trigger psoriasis. (1,2,6,13-15) REFERENCES 1.

Patient was treated with 4 mg of methylprednisolone given a starting dose of 24 mg / day and tappering off in accordance with the development of lesions. On the published literature, it is said that the administration of systemic corticosteroids provide rapid healing of psoriasis lesions, but can also make a flare of psoriasis lesions or turn into psoriasis pustulosis if its use is stopped abruptly. (1,2,9)

2.

3.

Patient also got a topical treatment clobetasol propionate cream added lanolin 10% and vaseline applied onto the upper half of the body in the morning and lower body half in the afternoon. On the control day 7, redness and squama reduced. Topical therapy was given desoximethasone cream added 3% salicylic acid, 10% lanolin and vaseline smeared on the body (except the face and neck) in the morning and afternoon. To overcome the itch given 1x10 mg cetirizine tablets at night. (1,2)

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