Presentation

This section presents all the characteristics of classic erythroderma. It will look at the range of physical symptoms as well as physiological changes that may appear symptomless but which manifest in diagnostic tests. It is especially important to understand these ‘hidden symptoms’ and know how to manage them before they ever start to manifest as physical symptoms.

Let me add here that symptoms, causes and personal history are inextricably linked. Your number one diagnostic tool is a notebook and pen! It is important you keep a diary of how your skin condition started, when it manifested and how it is developing. Memory is notoriously fallible, so best to write everything down. Think hard about what may have triggered the skin eruption. Had you taken any drugs? Some drugs have long half-lives so go back a couple of months or more. Any contact with potentially toxic chemicals? Our seas, for example, have unfortunately turned into open dumping grounds and may contain a cocktail of toxins and microorganisms. Do you have any family members who suffer from a skin condition, even if a mild one? It is good to inform your dermatologist of any genetic link to a potentially underlying condition.

Once armed with your notebook, you can proceed to attempt a self-diagnosis with the knowledge that a list of symptoms is not enough; a true differential diagnosis involves both positive data as well as negative data. If you want to see how it’s done, then watch House MD, and see how often Dr Gregory House gets it wrong before he hits on the correct diagnosis.





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Red Man Syndrome and l'homme rouge

Red Man Syndrome

Red Man Syndrome proper is now used to describe an erythroderma that remains idiopathic. The word 'idiopathic' is a wonderful medical term that means 'of unknown cause', or 'we haven't a clue'. You may find it of interest to read my Diary of a Red Man blog entry on idiopathy so that it is clear what we mean by the question, “What is the cause of your erythroderma?”

Pathophysiology

Pathophysiology refers to how the nature of a disease (its pathology) manifests through changes in bodily functions (or physiology). Sometimes these changes express themselves as symptoms but often they appear symptomless to the patient and only manifest in blood test results and other diagnostic techniques. Skin conditions have a complex pathology and often affect physiology in unexpected ways. 

Homeostatic Dysregulation

The redness of the skin is due to an increase in blood supply to the capillaries. When a layer of skin is shed, the new skin surface sometimes looks almost like normal skin, but unfortunately will return to the previous shade of red within a few hours. However, the real problem is not the redness itself but that the skin is dry and has lost the ability to sweat properly; the result is a dysfunction of the body’s normal temperature control and of its natural electrolyte balance.

Albumin Loss: Eat More Proteins

A defining characteristic of exfoliative dermatitis is, obviously, exfoliation. The first wave of skin loss happens about 2-6 days after the start of the first patch of erythema. The skin may peel off in small sheets; don’t pull it off as your skin is thinning and you may be prone to cracks and bleeding. Indeed, one clue to a possible underlying cause of erythroderma is that the skin is growing too quickly compared to its normal rate of growth. It is also shedding too quickly, a process that is usually imperceptible to most of us. This peeling is probably associated with a protein known as CEA and we shall look at this more closely in the section on etiology.

Erythroderma Overview

Erythroderma

Erythroderma is also known as Generalized Exfoliative Dermatitis. The word 'erythroderma' is derived from the Greek words erythros (meaning red) and derma (skin). In the early stages of the condition, you may hear your doctor mention the word 'erythema' as a description (which is just the medical term for redness) before a firm diagnosis can be established. It is also common that erythroderma develops from a different initial skin condition.

The basic symptoms of erythroderma are peeling red skin covering 90% or more of the skin surface. One problem with this definition is that once the redness has reached 90% it is already a very serious condition. It is therefore important to consult an experienced dermatologist as early as possible. Skin diseases have a habit of transforming themselves from one condition into another. Nobody yet really understands how or why they do this, but it is important that you, as a patient, monitor your initial skin rash for any changes.

Diary of a Red Man: The Ginger Red Man

Sitting in the back of a Bangkok taxi, my little daughter decides to entertain me with her latest sing-song.

“Run, run, run as fast as you can;
You can't catch me, I'm the Gingerbread Man!”

She then looks at me and says, “Daddy, you are the Ginger Red Man!”
That girl needs an agent. She looks pleased with her little pun and launches into a reprise:

“Run, run, run as fast as you can;
You can't catch me, I'm the Ginger Red Man!”

She laughs and gives me a big hug, then looks down at my exfoliating zombie hand, “I like red!” She could charm the skin off a snake.

Now, I knew that this was originally a long song but, try as I might, was unable to dredge up such an esoteric and banal memory. After a bit of strenuous research, here is a modern adaptation of the story.

Diary of a Red Man: Better Red Than Dead

Never before have I seen a doctor so visibly shocked. It was almost cartoon perfect, with hands raised in horror, eyes bursting out of their sockets and only pure professional decorum restrained him from emitting a shriek. “You have to be admitted to hospital... right now!” That was the start of the end of my life.

I didn’t even have time to gloat over my correct internet-driven self-diagnosis; had to satisfy myself in private later. Just two days prior to this, another dermatologist uncharacteristically admitted to being clueless as to my condition. Yet here was a doctor pushing me onto the critical list. If a misdiagnosis can be fatal, the advantage of a non-diagnosis is the freedom to seek another opinion. Especially when it appears that erythroderma can be fatal.