Erythrodermic psoriasis is a very inflammatory psoriasis that affects most of the body. It presents as generalized indurated erythema with diffuse exfoliation of fine scales, often accompanied by severe itching and pain (Fig. 9.1C). The patients may also present with fever, chills, rigors, arthralgias, and trouble maintaining core body temperature. Triggers for an episode of erythrodermic psoriasis include severe stress, discon tinuation of a systemic medication such as methotrexate, cyclosporine, or oral corticosteroids, diffuse phototherapy burns, and infections. Reports of patients with erythrodermic psoriasis suffering staphylococcal sepsis have been reported, and inpatient management with blood cultures and systemic antibiotics should be considered accordingly. Special attention must be paid to maintaining the appropriate fluid status in these patients, as they are highly susceptible to insensible losses.
Fig. 9.1. Clinical features of psoriasis. The typical psoriatic lesion is a sharply demarked erythematous plaque covered by silvery white scales, often appearing on the extensor sites of the extremities (A). Initial eruptions of psoriasis may exhibit a guttate distribution pattern and are often triggered by streptococcal infections (B). In a dark-skinned patient, erythrodermic psoriasis (C), a clinical subtype of the disease, affects the entire body surface. If the scalp is involved, the lesions typically extend a short distance beyond the region covered by terminal hair (D). Inverse psoriasis (E) is located at intertriginous areas and usually lacks scaling.
Pustular forms of psoriasis also exist (F, G). Localized forms of psoriasis include palmo-plantar psoriasis (H) and acrodermatitis continua suppurativa, or Hallopeau's disease, leading to severe dystrophy (I) or even loss of nails. Joint involvement (psoriatic arthritis) is frequently observed (J). Mild cases of nail involvement are characterized by small pits and yellowish discoloration of the nail plate (K), which were also created in a wax-model moulage, manufactured around 100 years ago (L, item 1766 from the collection of the Johann Wolfgang Goethe University, Frankfurt am Main). (Reproduced with permission from: N Engl J Med 2005; 352:1901)
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