Presented by Dr. Henry Foong, Ipoh, Malaysia
Abstract: A 65 year old man presented with a history of erythroderma for 3 weeks.
History: A 65 year old man presented with pruritic scaly erythematous patches on the chest about 3 weeks ago. Then he noticed the rashes spreading to the abdomen and back. Now it has spread to the face and both upper and lower extremities. He had no fever or other constituional symptoms. He denied taking any previous medication or health supplements.There was no past history of psoriasis or eczema.
Examination showed extensive multiple scaly erythematous patches on the abdominal wall, entire back and thighs. His scalp was scaly too. Over the lower back and abdominal wall, the erythema was confluent and generalised with multiple erythematous patches with islands of white in between. The lesions has an irregular margin. There is no follicular hyperkeratosis. The nails were normal. Both palms and soles appeared normal and not hyperkeratotic.
Abstract: A 65 year old man presented with a history of erythroderma for 3 weeks.
History: A 65 year old man presented with pruritic scaly erythematous patches on the chest about 3 weeks ago. Then he noticed the rashes spreading to the abdomen and back. Now it has spread to the face and both upper and lower extremities. He had no fever or other constituional symptoms. He denied taking any previous medication or health supplements.There was no past history of psoriasis or eczema.
Examination showed extensive multiple scaly erythematous patches on the abdominal wall, entire back and thighs. His scalp was scaly too. Over the lower back and abdominal wall, the erythema was confluent and generalised with multiple erythematous patches with islands of white in between. The lesions has an irregular margin. There is no follicular hyperkeratosis. The nails were normal. Both palms and soles appeared normal and not hyperkeratotic.
Photos:
Pathology:
The epithelium shows parakeratosis. The squamous epithelium does not show spongiosis or basal layer degeneration. The upper dermis shows mild perivascular and interstitial infiltrates of lymphocytes and eosinophils. The deep dermis is normal. Features do not suggest psoriasis.
INTERPRETATION
Features are compatible with pityriasis rubra pilaris without follicular involvement.
Diagnosis: Erythroderma - Extensive psoriasis vs pityriasis rubra pilaris
Reason for posting: This is an interesting diagnostic problem as whether erythroderma is due to PRP or psoriasis. Though there are features of psoriasiform changes over the extremioties and lower back, the presence of "islands of white" within patches of erythema is suggestive of PRP. As our experience with generalised PRP is limited, it is difficult to make a definitve diagnosis. A biopsy was done to help to make a more definitive diagnosis. In terms of treatment, however, oral retinoids such as acitretin would be useful in both conditions.
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