Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018




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Prof. Somashekhar Nimbalkar
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Chairman, Research Group, Charutar Arogya Mandal, Karamsad
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Ex-Member, Governing Body, National Neonatology Forum, New Delhi
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Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
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Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
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Professor and Head
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Saraswati Dental College
Lucknow
On Sep 2018




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Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




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Best regards,
C.S. Ramesh Babu,
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Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : August | Volume : 16 | Issue : 8 | Page : WC07 - WC12 Full Version

A Clinical Study of Patients with Erythroderma Attending a Tertiary Care Hospital in Eastern India


Published: August 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/53305.16715
Prerna Raj Gupta, Suchibrata Das, Alok KR Roy

1. Senior Resident, Department of Dermatology and Venereology, NRS Medical College, Kolkata, West Bengal, India. 2. Associate Professor, Department of Dermatology and Venereology, NRS Medical College, Kolkata, West Bengal, India. 3. Professor, Department of Dermatology and Venereology, NRS Medical College, Kolkata, West Bengal, India.

Correspondence Address :
Suchibrata Das,
827 M Ballygunge Place Ground Floor, Kolkata, West Bengal, India.
E-mail: suchibratadas@yahoo.com

Abstract

Introduction: Erythroderma is characterised by erythema and scaling over more than 90% of the body surface, a morphological reaction pattern of skin having innumerable underlying causes. Morbidity related to erythroderma is considerably high. The importance of finding the etiology with special emphasis on histopathology allow early and appropriate intervention for each case.

Aim: To observe etiological factors of erythroderma through appropriate haematological and biochemical investigations and histopathological examination.

Materials and Methods: An observational cross-sectional clinical study was done in the , Department of Dermatology and Venereology, NRS Medical College, Kolkata, West Bengal, India, from March 2016 to February 2017 on 37 successive admitted erythrodermic patients. Detailed clinical history recording with laboratory tests were performed. Clinical and laboratory data was analysed by percentage using MedCalc version 7.0.0.2 software. Chi-square test was used for data analysis and p-value <0.05 was considered as statistically significant.

Results: Of the 37 erythrodermic patients, commonest age group was 40 to 60 years, 16 (43.24%), Male:Female (M:F) ratio 2.1:1, duration of illness in majority from one to six months 20 (54.05%). Chronic dermatitis was the commonest cause of erythroderma, followed by Drug Induced erythroderma, Idiopathic and Malignancy in descending order. Psoriasis was the most common etiology 12 (32.43%). Combination of clinical and histopathological evaluation, diagnosed 31 (83.78%) cases.

Conclusion: Erythroderma has high morbidity with low mortality rate. Combination of good clinical history with histopathological evaluation confirms majority of cases and guide for proper management.

Keywords

Biochemical investigations, Etiology of erythroderma, Exfoliative dermatitis, Histopathological correlation

Erythroderma or Exfoliative Dermatitis (ED) is an inflammatory disorder characterized by erythema and scaling in a generalised distribution involving more than 90% of the body surface (1). It is a morphological reaction pattern of skin having innumerable underlying causes (2).

It poses significant risk of morbidity and mortality, in addition to the risks inherent to the underlying disease and its therapy. ED can be fatal, even when properly managed. The main cause of death in these patients are metabolic and electrolyte disturbances. The pathogenesis of ED is unclear. Currently, it is believed that the ED condition is secondary to an intricate interaction of cytokines and cellular adhesion molecules, including interleukins-1, 2 and 8, Intercellular Adhesion Molecule-1 (ICAM-1), and Tumor Necrosis Factor (TNF-α). These interactions result in a dramatic increase in the epidermal turnover rate, causing a higher than normal mitotic rate and an increase in the absolute number of germinative skin cells (3). Morbidity related to ED is considerably high as it is often a chronic disease, with debilitating signs and symptoms such as intense pruritus and scaling (4). Thus the importance of trying to find the etiology with special emphasis on histopathology allows early and appropriate intervention for each case.

Most of the earlier studies are from the western countries (1),(4),(5) and other parts of India (6),(7). There is a paucity of studies on ED in eastern India in the recent past, hence this study was undertaken to identify and analyse causes of ED in eastern region. The aim was to observe the clinical profile of erythroderma patients from history and clinical features and determine the etiological factors of the disease in those patients, through appropriate haematological, biochemical investigations and histopathological analysis.

Material and Methods

This was an observational cross-sectional clinical study, done in the Department of Dermatology and Venereology, NRS Medical College, a tertiary level hospital in Kolkata, West Bengal, India. It was approved by Institutional Ethics Committee, No/NMC/111, and conducted for a period of twelve months, from March 2016 to February 2017. In total, 37 successive erythrodermic patients were admitted during the study period, were included in the study.

Inclusion criteria: Patients clinically diagnosed and admitted with erythema and scaling involving more than 90% of body surface, and willing to adhere to the study, agreeing to do all investigations.

Exclusion criteria: Patients, who refused to give consent to participate in the study, were excluded.

Study Procedure

Demographic data was recorded. Detail history about onset and progression of erythroderma, prior skin diseases or associated illness if any, past episodes of ED, aggravating factors including drug intake were taken. Clinical examination was done. Thorough clinical examination including general and systemic examination, cutaneous examination, nail examination and hair examination using densitometry per sq. cm of scalp (PROSmart 5X) were done.

Laboratory investigations such as complete haemogram, blood glucose, urea, creatinine, liver function tests and serum electrolytes were performed. Abdominal ultrasound, chest radiograph, Fine Needle Aspiration Cytology (FNAC) of lymph nodes, peripheral smear, tzanck smear and patch testing was done in all cases. Skin biopsy from the most characteristic area for histopathological examination was performed in all the cases.

Statistical Analysis

Data was compiled electronically into Excel programme sheet. Clinical and laboratory data was analysed by percentage using MedCalc version 7.0.0.2 software and included in table and text. Chi square test was used for data analysis and p-value <0.05 was considered as statistically significant.

Results

Out of the 37 ED patients, age ranged from 1 year to 80 years, with average age being 47.7±18.09 years. Commonest age group was 40 to 60 years (16/43.24%), followed by above 60 years group (10/ 27.03%). 25 patients were male, 12 were female (M:F 2.1:1).

The duration of illness ranged from two weeks to as long as 12 months, majority from 1-6 months (20/54.05%). Seven cases of drug induced ED and two cases of pemphigus related ED were of less than one month duration (Table/Fig 1). Provides the etiology and duration of disease. Mycosis Fungoides (Cutaneous T-Cell Lymphoma) presented with history of more than six months duration (one case).

All the patients presented with certain specific complaints/ symptoms as depicted in (Table/Fig 2). All the 37 patients were showing scaling, redness and skin eruptions. Site of onset of the disease according to the cause of ED as depicted by (Table/Fig 3), (Table/Fig 4). Three cases had more than one region of onset of the disease lesion. Majority (six cases) of drug induced ED started from face, psoriatic ED started from extremities (six cases), (three cases) of pemphigus foliaceous induced erythroderma started from seborrheic area such as head and neck (Table/Fig 3), (Table/Fig 4).

Most common aggravating factor, was winter season (10/27.02%), followed by intake of drugs (9/24.03%), summer season (6/16.20%), homeopathic medication in 5 (13.05%) cases, ayurvedic medications in 3 (8.10%), contact with cement in 2 (5.41%), parthenium in 1 (2.70%). Phenytoin in 3 (8.10%) caeses was the most common drug, followed by carbamazepine in 1 (2.70%) (Table/Fig 5). Other drugs elicited were dapsone in1 (2.70%), lamotrigine 1 (2.70%), levetiracetam 3 (8.10%), valproate 2 (5.40%), oral hypoglycemic agent namely glipizide 1 (2.70%), metoprolol in 1 (2.70%) cases. There was history of intake of more than one drug in 4 (10.80%) cases. Also, there was precipitation of ED due to steroid withdrawal in 2 (5.40%) cases.

On general examination, 7 (18.91%) patients had tachypnoea, 2 (5.40%) had tachycardia, and 11 (29.72%) had high blood pressure. Presence of pedal oedema 26 (70.27%) came as positive clinical finding [statistically significant, p=0.0214]. Anaemia was present in 21 (56.76%), jaundice in 6 (16.22%), enlarged lymph node in 7 (18.29%) cases. Cervical and axillary lymphnodes were most commonly involved followed by inguinal (discrete, nontender and firm, dermatopathic lymphadenopathy), hepatomegaly (mild to moderate, mostly in drug induced erythroderma) in 6 (16.22%) cases. Pedal oedema of pitting type was observed in 26 (70.2%) of cases. However, among them, 24 (64.86%) patients had hypoalbuminemia. Lymphnode enlargement was a result of reactive hyperplasia, and regressed over a period of one to two weeks, as the ED was treated. Hepatomegaly was seen in 6 (16.22%) of cases and all were of drug induced ED. None of our patients had splenomegaly (Table/Fig 6).

On cutaneous examination, erythema and scaling was observed in 100% of the patients. Scales were large, easily detachable in acute cases whereas smaller size in chronic cases .Papules in 22 (59.45%) cases, pustules in 7 (18.91%) cases, plaques in 10 (27.02%) cases, 2 (5.40%) cases showed vesicles and bulla. Exudation was present in12 (32.43%) cases, 5 (13.51%) showed crusting and 4 (10.81%) showed ulcerations, 8 (21.62%) patients had lichenification and 7 (18.91%) patients had pigmentation (Table/Fig 7). Nose sign of erythroderma was present in 11 (29.7%) of cases and Deck chair sign in 1 (2.70%) of cases.

Nail surface change included smooth shiny nails, pitted nails or longitudinally ridged nails. Colour change seen were opaque nails, blackish nails and yellowish nails. Nail dystrophy was observed in 7 (18.91%) patients. Hyperkeratosis was seen in 6 (16.21%) patients and nail infection, namely onychomycosis in 6 (16.21%).

The average hair density was 120.54±37.33 per sq. cm., lower than the average normal hair density in asian that is 175±54 hairs/cm2 (8). Chronic scaling led to loss of body hair with or without madarosis, was observed in 16 (43.24%) patients. In this study, hair colour change was hypopigmentation (brown hair) or depigmentation (grey hair) was observed in 8 (21.62%) patients. Hair texture was dull, lustreless, brittle hair while some had greasy frizzy hair.

Anaemia was found in 25 (67.56%) patients, leucocytosis in 13 (35.13%) patients, 12 (32.43%) patients had eosinophilia whereas 5 (13.51%) patients had low eosinophil count. Raised Erythrocyte Sedimentation Rate (ESR) was seen in 15 (40.54%) patients.

Decrease in total serum protein level was seen in 6 (16.21%) and low albumin in 24 (64.86%), 2 (5.40%) patients had increased and 1 (2.70%) patient has low serum globulin. 5 (13.51%) patients showed altered Albumin:Globulin (A:G) ratio despite normal total serum protein. Liver enzymes was deranged in 12 (32.43%), altered lipid profile was in 31(83.87%) patients. Of them, 8 (21.62%) had elevated serum total cholesterol, 18 (48.64%) had lowered serum High Density Lipid (HDL) and 20 (54.05%) had elevated serum triglyceride. More than one variable was deranged in most patients, 32 (86.48%) out of 37. Low serum sodium level was seen in 16 (43.24%) patients, 6 (16.21%) patients had low serum potassium levels. No significant result for chest radiograph, abdominal ultrasound was found in any patient.

Histopathological examination: Biopsy for histopathological examination was done in all cases, in an attempt to confirm the provisional diagnosis. Histopathological examination was helpful for diagnosis in 21 (56.75%) out of 37cases. Whereas the rest 16 (43.24%) showed non specific histopathological features and a final diagnosis was made based on combined clinical and histopathological findings (Table/Fig 8), (Table/Fig 9).

Etiology of erythroderma: Clinical diagnosis was supported by histopathology in 10 cases (83.33%) of Psoriasis, 1 (100%) in airborne Contact Dermatitis, 1 (100%) in pemphigus erythemetosus, and 4 (80%) in pemphigus foliacius. In rest of 5 cases histopathological report was inconclusive but not against the clinical diagnosis was considered as the etiological factor. After thorough clinical and histopathological evaluation, 31 (83.78%) cases could be brought to a diagnosis. Psoriasis was the most common etiology (12/32.43%), followed by drugs( 9/24.32%), pemphigus foliaceous (4/ 10.84%), contact dermatitis (1/2.70%), Nonbullous Ichthyosiform Erythroderma [NBIE] (1/2.70%), Darier disease (1/2.70%), pemphigus vulgaris (1/2.70%) and mycosis fungoides (1/2.70%). However, in 6 (16.21%) no diagnosis reached and so it was called Idiopathic. Broadly classifying, chronic dermatoses 21 (56.75%) were the most common cause of erythroderma, followed by drug induced (9 /24.32%), 6 /16.21% were idiopathic and 1/2.70) was malignancy (mycosis fungoides) (Table/Fig 8), (Table/Fig 9).

Discussion

Exfoliative dermatitis is a potentially life-threatening dermatoses with significant risk of morbidity (9). It is very difficult to identify the cause in fully involved state, and hence its management. A detailed and prompt history, clinical and histological examination and other relevant lab investigations are required to know the etiology. In this study, the commonest age group was 40 to 60 years (43.24%), which is similar to other studies of (4),(5),(6). The average age of the patient in this study being 47.7±18.09 years, which is similar to earlier studies (7),(10),(11).

Male to female ratio was 2.1:1 in this study which was in accordance with the earlier studies (10),(12),(13). Reason for male predominance may be the higher treatment seeking attitude in the current socioeconomic scenario whereas female are hesitant for taking institutional management. Thirteen patients (35.14%) had acute onset of condition, among them 7 (18.91%) were cases of drug induced ED. Remaining 24 (64.86%) patients had insidious onset, most common of them were ED due to psoriasis. An acute onset was seen in 32% of patients in one study and in another 69% (12),(14). Commonest symptoms like scaling, redness, itching and skin rash, fever, arthralgia etc present in the present study were comparable to other studies (12),(13),(15). Most common aggravating factor was winter season 11 (29.72%). This maybe because majority of cases of ED turned out to be psoriatic in origin and psoriasis is known to aggravate in winter season (3).

In 24.3% of ED cases, drugs were the offending factor. Drugs implicated were phenytoin, carbamazepine, lamotrigine, metoprolol, glipizide and dapsone. In two cases rampant intake of steroids and its withdrawal in patients with psoriasis precipitated the condition. Though percentage of drug as etiology is higher in our study it exactly corroborates with study of Mathew R et al., (15). This may be because drug hypersensitivity syndromes usually progress to ED and the above mentioned drugs mostly causes drug hypersensitivity. Lymphadenopathy was seen in 7(18.9%) of cases, in other studies it was ranged from 21% to 80% of cases (5),(10),(13),(14),(16). Lymphnodes were a result of reactive hyperplasia, and regressed over a period of 1 to 2 weeks, as the ED was treated. In a series by Pal and colleagues lymphadenopathy was present in 55.5% of cases and in all cases it was dermatopathic lymphadenopathy except in one which showed Hodgkin’s lymphnode. Pedal oedema of pitting type was observed in 26 (70.27%) of cases (13). However, among them, 24 (64.86%) patients had hypoalbuminemia. Pedal oedema has been reported in the range of 36% to 80% of cases in previous studies (10),(12),(15),(17). With gradual control of erythroderma and supplementation of high protein diet, oedema subsided in all cases.

Hepatomegaly was seen in 16.2% of cases and all were of drug induced ED. The studies by Rafael BE et al., Pal S et al., Sudha R et al., hepatomegaly was reported in 14%, 25.5% and 8% respectively (13),(18),(19). None of the patients had splenomegaly in the present study. However, a few previous studies have presented splenomegaly in 8% and 14% respectively (18),(19). Significance of splenomegaly in ED is not known.

Cutaneous signs: Irrespective of etiology, clinical feature of ED includes scaling and erythema, were seen in all patients. Scales were large, easily detachable in acute cases whereas smaller size in chronic cases. These findings corroborates with Previous studies, where generalized erythema and scaling seen in upto 100% of cases (13),(15),(19).

The ‘Nose Sign’ of ED has been reported by Pavithran (20). In our study it was present in 29.7% of cases, as compared to 53.5% in another study (21). The reason for this phenomena is suggested as greater exposure of area to sunlight, with its presumptive antimitotic activity (20). ‘Deck chair sign’ described in papulo-erythroderma of Ofuji, was seen in 2.70% of our patients, which was a case of Parthenium dermatitis. This was in accordance with Pal S and Haroon TS who described this sign in 5.5% of their patients (13). Chronic scaling leads to Loss of body hair with or without madarosis, was observed in 43.24% in the present study. Hair loss was observed in 53.3%, 30% and 24%, cases in different studies (13),(19),(21). Lichenification of skin was seen in 21.62% of our patients, it was reported in 23.3% and 34.4% of the cases in other studies (13),(22). May be due to continous scratching. Usual Nail changes of ED is polished or shiny nails of chronic friction, other changes like pitting of nails, subungual hyperkeratosis (may be the changes due to psoriasis), nail discoloration, beau’s lines and nail dystrophy were observed in 51.35% of cases supported by similar findings in earlier studies (12),(15). But these changes are non specific as ED of long duration may cause hair loss or nail dystrophy regardless of its origin.

Laboratory findings: Different studies on ED shows mild anaemia, leucocytosis, eosinophilia, increased ESR, hypoproteinemia, altered albumin to globulin ratio, elevated levels of blood urea and creatinine (12),(13),(15),(16),(18),(21),(23),(24). Laboratory findings of the present study were comparable with these studies. Laboratory evaluation of patients with ED is generally not helpful in determining a specific diagnosis. Mild anaemia is relatively common and has been attributed to the chronic inflammatory process. Other frequently reported non specific findings include leukocytosis, eosinophilia, elevated erythrocyte sedimentation rate, abnormal serum protein, electrophoresis with a polyclonal elevation in the gamma globulin region, and elevated IgE levels, though other study have been found a possible association of eosinophilia and high levels of LDH with paraneoplastic ED (PE) (11),(25). Hypoproteinemia could be due to protein loss through scaling, chronic malnutrition or dilution due to hypervolumia, raised enzymes were more specific to ED with maximum patients have drug induced ED (26). Serum electrolyte imbalance usually in the form of hyponatremia, hypokalaemia, hypocalcaemia (26). This highlights the importance of correction of fluid and electrolyte imbalance in the management of ED. Comparison of earlier studies with present study for etiology of ED is shown in (Table/Fig 10) (12),(13),(15),(19),(21),(23).

Psoriasis was the most common cause accounting for 32.4% of cases. Similar findings were shown in the previous Indian studies (Table/Fig 10) (12),(15),(19),(21). Pemphigus group of disorders as a cause of ED was seen in 16.2% of cases, this incidence was slightly higher than the shown in previous studies (12),(13),(15). Among them, four cases were due to pemphigus foliaceous, one was due to Pemphigus erythematosus and one was a case of previously diagnosed pemphigus vulgaris under treatment with high dose long term corticosteroid who presented with ED following sudden injudicious withdrawal of the steroid.

Contact dermatitis and Mycosis fungoides as cause was seen in 2.7% of the study sample size, which was correlating with previous studies (12),(13). In 16.21% of cases, etiological factor for ED could not be determined inspite of thorough history, clinical examination, blood investigations and skin biopsy for histopathological examination. Patients in this group were elderly with a long duration of ED having severe itching. To rule out cutaneous lymphoma as the cause, it is advised to do multiple biopsies in such cases and it is also imperative to have long term follow.

Histopathology helped in correlating and confirming the etiology of ED in 56.75% of cases and did not help in 43.24% of cases. In a study by Hulmani M et al., histopathological correlation was found in 80% cases, by Rym BM et al., (21),(23). Histopathological correlation was found in 74% of patients, in Bandyopadhyay and colleagues (15). there was correlation in 52% of cases. Histopathologically identification of psoriasis as the underlying cause of ED is more successful than elucidation of other etiologies. In our study 83.33% of psoriasis patients were confirmed histologically.

Limitation(s)

As the study period was short, the sample size obtained was small, observational studies must have larger number of cases to get more realistic inference.

Conclusion

In erythroderma, the main challenge lies in identifying the underlying cause and managing it. In this study psoriasis was the most common etiology followed by drug reactions. Histopathological finding was helpful in 56.75% of cases. Combination of detail clinical history, thorough examination combined with histopathological evaluation confirms the majority of cases as well as guiding for proper management. Idiopathic causes of erythroderma reduced with combination of these three approaches, which leads to improved prognosis.

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DOI and Others

DOI: 10.7860/JCDR/2022/53305.16715

Date of Submission: Nov 14, 2021
Date of Peer Review: Jan 15, 2022
Date of Acceptance: May 11, 2022
Date of Publishing: Aug 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
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• iThenticate Software: Jun 21, 2022 (18%)

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