Massive Skin Breakdown Causing Dehydration and Widespread Impetigo: A Case of Erythrodermic Psoriasis in a Pediatric Patient
Introduction: As the largest organ, the skin plays many important roles including providing a protective barrier, preventing dehydration, and protecting against invasive organisms. When skin breakdown occurs, the body is subject to many abnormalities.
Case Description: An eleven year old female presents from dermatology clinic secondary to massive skin breakdown. Three months ago, she had non-painful bumpy rash on her abdomen and was seen by dermatology and started on triamcinolone cream, hydrocortisone cream, pimecrolimus cream, and oral cephalexin. Rash resolved after two months and she stopped all prescriptions medications and started minerin cream. Two weeks prior to admission, rash returned but was now characterized as flaky, itchy, painful, and more diffuse and prominent. It now covered her entire body but spared palms, soles, and mucosal membranes. She had multiple oozing wounds but no purulent drainage. She was found to be tachycardic and had lost 5kgs since she was seen 3 months ago. Other than eosinophilia, mildly elevated CRP, and hypoproteinemia, all lab work was within normal limits. She was given a fluid bolus and started on increased maintenance intravascular fluids. She was also started on ancef, clindamycin, and acyclovir. Skin biopsy was performed at dermatology which eventually showed erythrodermic psoriasis with overlying MRSA impetigo.
Discussion: Two to three percent of the world’s population suffers from psoriasis with only two percent of those suffering from erythrodermic psoriasis. Erythrodermic psoriasis is a rare and life-threatening form of psoriasis with death estimated in 10-65% secondary to pneumonia, septicemia, and heart failure. Symptoms include redness, discoloration, and shedding of over seventy-five to ninety percent of the skin, severe pain and itching, temperature instability, and tachycardia. The pathogenesis is not well understood but recent studies have associated the disease with dysregulation of T helper 2 cells. Typical demographics show male predominance with average age between forty and sixty with only four cases reported in pediatric medicine. A pre-existing dermatosis is the most common cause of erythroderma often triggered by allergic reaction, starting or stopping medications, infections, severe illness, severe sunburn, stress, or alcohol. Lab findings are generally non-specific with mild leukocytosis and eosinophilia, elevated inflammatory markers, and massive protein loss. Initial management of erythroderma is replacement of fluids, electrolytes, and adequate nutrition. Skin management should consist of emollients and low-potency corticosteroids. Secondary infections require antibiotics. Continued post hospital management often requires topical treatments, oral treatments, or biologics.
Conclusion: Upon extensive literature review, only four other cases of pediatric erythrodermic psoriasis have been reported making it a very rare disease but early diagnosis and management is critical for positive outcomes. Physicians should be aware of this exceedingly rare disease.
