Erythroderma, Severe Psoriasis … or Not?

1Carilion Clinic Virginia Tech Carilion Internal Medicine Residency Program, Roanoke, VA

Meeting: Hospital Medicine 2011, May 10-13, Dallas, Texas.

Abstract number: 313

Case Presentation:

A 45‐year‐old woman presented from a rescue mission with 1 month of worsening pruritis and a scaling rash. She had multiple emergency room visits during this time for a pruritic, scaly eruption that was diagnosed as psoriasis. Despite treatment with oral and topical corticosteroids, the patient continued to experience progression of the rash to erythroderma. Past medical history consisted of AIDS with poor compliance to antiviral therapy, Pneumocystis jiroveci pneumonia, HIV dementia, and COPD. On hospital admission, physical examination was significant for generalized erythroderma and fissured, hyperkeratotic plaques on the bilateral dorsal hands, thighs, and abdomen. There was subtle subungal hyperkeratosis with normal nail plates. Pertinent laboratory findings included albumin 2.6 g/dL, prealbumin 6.4 mg/dL (normal, 18–38 mg/dL), HIV viral load 1.48 million copies/mL, CD4 count 348 cells/μL. Skin scraping revealed numerous scabies mites. She was diagnosed with erythrodermic crusted scabies and treated with oral ivermectin on days 1, 2, 8, 9, and 15 and permethrin 5% topical cream every 2 days for 2 weeks. The crusted plaques resolved, and skin healed with some residual erythema.

Discussion:

Crusted scabies, formerly Norwegian scabies, is a severe form of infestation by Sarcoptes scabiei variant homini and must be considered in the differential diagnosis of a patient presenting with erythroderma. The condition is most often seen in immunosuppressed patients. Crusted scabies can be confused with psoriasis because of the extensive hyperkeratotic plaques that may be present on the extensor surfaces as well as the palms and soles. It can be differentiated from psoriasis by intense pruritis, worse at night, and “dirty”‐appearing hyperkeratosis (instead of silvery white scale). Treatment for psoriasis can cause a devastating progression of scabies infection and ultimately lead to erythroderma. Erythroderma is defined as erythema and scale involving greater than 90% of the body surface area and is considered a dermatologic emergency, as rapid skin turnover can lead to a negative nitrogen balance. In addition, heat and fluid loss through the skin can result in fluid shifts and lead to high‐output cardiac failure. Our patient was treated with a recently described regimen of repeated doses of ivermectin along with frequent permethrin topical treatments. In the past, a single dose of ivermectin had been utilized with permethrin, and this new regimen has been postulated to reduce the risk of recurrence.

Conclusions:

Misdiagnosis of crusted scabies can have life‐threatening consequences including erythroderma.

Disclosures:

K. Khosa ‐ none; E. Cheikh ‐ none; M. Phillips ‐ none; T. Kerkering ‐ none

To cite this abstract:

Khosa K, Cheikh E, Phillips M, Kerkering T. Erythroderma, Severe Psoriasis … or Not?. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 313. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/erythroderma-severe-psoriasis-or-not/. Accessed November 19, 2019.

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