drug induced exfoliative dermatitis

Since cutaneous function as a multiprotective barrier is so disrupted in exfoliative dermatitis, the body loses heat, water, protein and electrolytes, and renders itself much more vulnerable to infection. The authors declare that they have no competing interests. Chang CC, et al. Theoretically, any drug can trigger a reaction, but the medications most associated with this disorder are: Allopurinol; Antiepileptic medications; Barbiturates Yamada H, Takamori K. Status of plasmapheresis for the treatment of toxic epidermal necrolysis in Japan. Polak ME, et al. 1993;129(1):926. It can lead to pain, appear on large parts of the body and may require hospitalization. 2023 BioMed Central Ltd unless otherwise stated. Int Arch Allergy Immunol. Blood gas analysis, glucose and creatinine levels together with electrolytes should be evaluated and therapy should be modified accordingly. 2015;56(4):298302. Still, treatment indication, choice and dosage remain unclear, and efficacy yet unproven. The more common forms of erythroderma, such as eczema or psoriasis, may persists for months or years and tend to relapse. Trigger is an exotoxin released by Staphylococcus aureus [83]. Diagnosis in a routine setting is based on patch test (PT) while skin test (prick and intradermal tests) with a delayed reading are contraindicated in these patients [72]. View ABRIGO_Worksheet #8 Drug Study_Endocrine System.pdf from NCM 06 at Southern Luzon State University (multiple campuses). Dermatologic disorders occasionally present as exfoliative dermatitis. Allergol Int. Arch Dermatol. . Correspondence to Insidious development of the erythroderma, progressive debilitation of the patient, absence of previous skin disease and resistance to standard therapy are features that may suggest an underlying malignancy.6,11, Erythroderma is also associated with disorders that cannot easily be classified into groups. Epub 2018 Aug 22. Before This site needs JavaScript to work properly. A case of anti-BP230 antibody-positive dyshidrosiform bullous pemphigoid secondary to dipeptidyl peptidase-4 inhibitor in a 65-year-old Filipino female Common acute symptoms include abdominal pain or cramps, nausea, vomiting, and diarrhea, jaundice, skin rash and eyes dryness and therefore could mimic the prodromal and early phase of ED. 543557. Clipboard, Search History, and several other advanced features are temporarily unavailable. Khalil I, et al. Check the full list of possible causes and conditions now! Br J Dermatol. Adverse cutaneous drug reaction. Lin YT, et al. Background: Panitumumab is an EGFR inhibitor used for the treatment of metastatic colorectal cancer (mCRC), even if its use is related to skin toxicity. 2013;57(4):58396. Orphanet J Rare Dis. Among the anti-tubercular drugs exfoliative dermatitis is reported with rifampicin, isoniazid, ethambutol, pyrazinamide, streptomycin, PAS either singly or in combination of two drugs in some cases. It is necessary to obtain as soon as possible a central venous access and to start a continuous monitoring of vital signs. Mona-Rita Yacoub. 2010;62(1):4553. In ED increased levels of FasL have been detected in patients sera [33]. Management of patients with a suspected drug induced exfoliative dermatitis, acute generalized exanthematous pustulosis, algorithm of drug causality for epidermal necrolysis, European registry of severe cutaneous adverse reactions to drugs. Recently, a meta-analysis based on 6 retrospective studies evaluating the role of corticosteroids alone or together with IVIG has been published [107]. doi: 10.1016/j.jaad.2013.05.003. A heterogeneous pathologic phenotype. Kaffenberger BH, Rosenbach M. Toxic epidermal necrolysis and early transfer to a regional burn unit: is it time to reevaluate what we teach? Ko TM, et al. PubMed Central The most important actions to do are listed in Fig. Increased level of retinoid acid could be responsible for keratinocytes apoptosis [99]. Other cases are ultimately classifiable as another dermatosis. A multidisciplinary team is fundamental in the therapeutic management of patients affected by exfoliative DHR. If it is exfoliative dermatitis that's drug induced, it's easy to treat . Vasoactive amines may be necessary in case of shock. EM usually occurs in young adults of 2040years of age [13], with women affected more frequently than men (1.5:1.0) [14]. Recurrence occurs in around one-third of cases [15] and there is a genetic predisposition for certain Asian groups [16]. Proc Natl Acad Sci USA. J Invest Dermatol. Early enteral nutrition has also a protective effect on the intestinal mucosa and decreases bacterial colonization. Huang SH, et al. J Allergy Clin Immunol. Erythema multiforme and toxic epidermal necrolysis: a comparative study. exfoliative conditions. In the 5 studies that concluded negatively for IVIG, the dosage was below 0.4g/kg/day and treatment was maintained for less than 5days. Reticuloendothelial neoplasms, as well as internal visceral malignancies, can produce erythroderma, with the former being the more predominant cause. Plasmapheresis may have a role in the treatment of ED because it removes Fas-L [96], other cytokines known to be implied in the pathogenesis (IL-6, IL-8, TNF-) [97, 98]. Roujeau JC, et al. Paulmann M, Mockenhaupt M. Severe drug-induced skin reactions: clinical features, diagnosis, etiology, and therapy. Consultation with an oncologist who is well-versed in treatment of cutaneous T-cell lymphoma is advisable once the disease progresses to the tumor stage. Medication use and the risk of StevensJohnson syndrome or toxic epidermal necrolysis. MRY, MGS, EN and GC designed the study, selected scientifically relevant information, wrote and revised the manuscript. In vitro diagnostic assays are effective during the acute phase of delayed-type drug hypersensitivity reactions. Gueudry J, et al. Allergy. EMM is characterizes by target lesions, circular lesions of 1-2cm of diameter, that are defined as typical or atypical that tends to blister. Abe J, et al. Effects of treatments on the mortality of StevensJohnson syndrome and toxic epidermal necrolysis: a retrospective study on patients included in the prospective EuroSCAR Study. Kirchhof MG et al. The induction dosage in EMM is usually 1mg/kg/day that should be maintained until a complete control of the skin is obtained. J Am Acad Dermatol. Clin Exp Dermatol. Szary syndrome, the leukemic variant of mycosis fungoides, is also associated with exfoliative dermatitis. Mortality rate of patients with TEN has shown to be directly correlated to SCORTEN. It is not completely clear whether EM and SJS are separate clinical entities or if they represent two different expressions of a single disease process. It is a reaction pattern and cutaneous manifestation of a myriad of underlying ailments, including psoriasis and eczema, or a reaction to the consumption of . The lymphocyte transformation test in the diagnosis of drug hypersensitivity. 2009;151(7):5145. See this image and copyright information in PMC. Samim F, et al. ALDEN has shown a good accuracy to assess drug causality compared to data obtained by pharmacovigilance method and casecontrol results of the EuroSCAR casecontrol analysis for drugs associated with TEN. J Allergy Clin Immunol. Etoricoxib-induced toxic epidermal necrolysis: successful treatment with infliximab. asiatic) before starting therapies with possible triggers (e.g. [Stevens-Johnson Syndrom and Toxic Epidermal Necrolysis--based on literature]. Patients with underlying skin disorders may respond much more slowly to therapy, but clearing almost always occurs eventually. In particular, a specific T cell clonotype was present in the majority of patients with carbamazepine-induced SJS/TEN and that this clonotype was absent in all patients tolerant to the drug who shared the same HLA with the SJS/TEN patients [45]. Do this 2 to 3 times a week. Google Scholar. 1984;101(1):4850. Efficacy of plasmapheresis for the treatment of severe toxic epidermal necrolysis: is cytokine expression analysis useful in predicting its therapeutic efficacy? Exfoliative dermatitis has been reported in association with hepatitis, acquired immunodeficiency syndrome, congenital immunodeficiency syndrome (Omenn's syndrome) and graft-versus-host disease.2,1517, In reviews of erythroderma, a significant percentage of patients (about 25 percent) do not receive a specific etiologic diagnosis. In an open trial on cyclosporine in 29 patients with TEN, the use of Cys A for at least 10days led to a rapid improvement without infective complications [112]. Detection of a herpes simplex viral antigen in skin lesions of erythema multiforme. Bullous pemphigoid is characterized by large, tense bullae, but may begin as an urticarial eruption. It is challenging to diagnose this syndrome due to the variety . Burns. Chung and colleagues found an high expression of this molecule in TEN blister fluid [39] and confirmed both in vitro and in vivo its dose-dependent cytotoxicity [39]. 2009;182(12):80719. Download Free PDF. 2002;109(1):15561. 1996;135(1):611. Patients should be educated to avoid any causative drugs. Skin testing and patch testing in non-IgE-mediated drug allergy. Acute processes usually favor large scales, whereas chronic processes produce smaller ones. 2012;43:10115. 00 Comments Please sign inor registerto post comments. Fritsch PO. Therefore, the clinician should always consider drugs as a possible cause. Antiviral therapy. The EuroSCAR-study. 2013;69(2):173174. Genome-wide association study identifies HLA-A* 3101 allele as a genetic risk factor for carbamazepine-induced cutaneous adverse drug reactions in Japanese population. A severity-of-Illness score for toxic epidermal necrolysis (SCORTEN) has been proposed and validated to predict the risk of death at admission [81]. 22 Abacavir-induced hypersensitivity syndrome is strongly associated with HLA-B*5701 during treatment . Lerch M, Mainetti C, Terziroli Beretta-Piccoli B, Harr T. Clin Rev Allergy Immunol. Epub 2022 Mar 9. Chan HL, et al. The .gov means its official. In most severe cases the suggested dosage is iv 11.5mg/kg/day. The most common of these are psoriasis, atopic dermatitis, seborrheic dermatitis, contact dermatitis and pityriasis rubra pilaris. J. Two Cases in Adult Patients. J Dtsch Dermatol Ges. doi: 10.4103/0019-5154.39732. PubMed The management of toxic epidermal necrolysis. J Allergy Clin Immunol. These measures include bed rest, lukewarm soaks or baths, bland emollients and oral antihistamines.2527, In patients with chronic idiopathic erythroderma, emollients and topical steroids may be effective. Even patients with clear histories of preexisting dermatoses tend to have biopsies that are not diagnostic when they present with erythroderma.2, Laboratory evaluation of patients with erythroderma is generally not very helpful in determining a specific diagnosis. GULIZ KARAKAYLI, M.D., GRANT BECKHAM, M.D., IDA ORENGO, M.D., AND TED ROSEN, M.D. Ann Burns Fire. Napoli B, et al. Fritsch PO. Bourgeois GP, et al. Letko E, Papaliodis DN, Papaliodis GN, Daoud YJ, Ahmed AR, Foster CS. CAS In this study, 965 patients were reviewed. Umbilical cord mesenchymal stem cell transplantation in drug-induced StevensJohnson syndrome. Atypical target lesions manifest as raised, edematous, palpable lesions with only two zones of color change and/or an extensive exanthema with a poorly defined border darker in the center(Fig. Theoretically, any drug may cause exfoliative dermatitis. government site. 2005;62(4):63842. Pichler WJ, Tilch J. McCormack M, et al. Disasters. 2015;21:13343. No uniformity of opinion exists concerning the best treatment for cutaneous T-cell lymphoma. Systemic corticosteroids: These are the most common used drugs because of their known anti-inflammatory and immunosuppressive effect through the inhibition of activated cytotoxic T-cells and the production of cytokines. Usually the amount of calories is 15002000kcal/day and the velocity of infusion is gradually increased based on patients tolerability [92]. Ramirez GA, Yacoub MR, Ripa M, Mannina D, Cariddi A, Saporiti N, Ciceri F, Castagna A, Colombo G, Dagna L. Biomed Res Int. Drug induced exfoliative dermatitis (ED) are a group of rare and severe drug hypersensitivity reactions (DHR) involving skin and usually occurring from days to several weeks after drug. Wolkenstein P, et al. Lymphocyte transformation test (LTT) performed as described by Pichler and Tilch [77] shows a lower sensitivity in severe DHR compared to less severe DHR [78] but, if available, should be performed within 1week after the onset of skin rash in SJS and TEN [79]. The overall mortality rate is roughly 30%, ranging from 10% for SJS to more than 30% for TEN, with the survival rate worsening until 1year after disease onset [9, 1821]. Valeyrie-Allanore L, et al. The prognosis of cases associated with malignancy typically depends on the outcome of the underlying malignancy. EMs mortality rate is not well reported. 1997;19(2):12732. Del Pozzo-Magana BR, et al. ALDEN, an algorithm for assessment of drug causality in StevensJohnson Syndrome and toxic epidermal necrolysis: comparison with case-control analysis. . Google Scholar. CD94/NKG2C is a killer effector molecule in patients with Stevens-Johnson syndrome and toxic epidermal necrolysis. J Popul Ther Clin Pharmacol. Med., 1976, 6, pp. Interferon alfa (Roferon-A, Intron A, Alferon N), Isoniazid (Laniazid, Nydrazid; also in Rifamate, Rimactane), Isosorbide dinitrate (Isordil, Sorbitrate), Para-amino salicylic acid (Sodium P.A.S. Moreover Mawson A and colleagues hypothesized that the efficacy of plasmapheresis is able to reduce serum level of vitamin A. 2012;66(3):1906. PubMed These include a cutaneous reaction to other drugs, exacerbation of a previously existing condition, infection, metastatic tumor involvement, a paraneoplastic phenomenon, graft-versus-host disease, or a nutritional disorder. [71] realized an algorhitm named ALDEN (algorithm of drug causality for epidermal necrolysis) which helps to establish a cause/effect relationship as probable or very probable in 70% of cases. 2008;49(12):208791. The administration of a single dose of 5mg/kg was able to stop disease progression in 24h and to induce a complete remission in 614days. Diclofenac sodium topical solution, like other NSAIDs, can cause serious systemic skin side effects such as exfoliative dermatitis, SJS, and TEN, which may result in hospitalizations . Copyright 2023 American Academy of Family Physicians. In order to rule out autoimmune blistering diseases, direct immune fluorescence staining should be additionally performed to exclude the presence of immunoglobulin and/or complement deposition in the epidermis and/or the epidermal-dermal zone, absent in ED. Notably, Agr inhibitors have not yet been more rigorous pre-clinical testing using the established analyzed using rigorous testing with systemic applica standards for drug development. Fischer M, et al. CAS J Am Acad Dermatol. Paradisi et al. Dent Clin North Am. . . Chung WH, Hung SI. . 2015;64(3):2779. . 1). sharing sensitive information, make sure youre on a federal 2007;48(5):10158. 2012;167(2):42432. Also a vesical catheter should be placed to avoid urethral synechiae and to have a precise fluid balance. Toxic epidermal necrolysis and StevensJohnson syndrome. SJS and TEN are two overlapping syndromes resembling severe burn lesions and characterized by skin detachment. Clin Mol Allergy 14, 9 (2016). Drugs that have been implicated in the causation of LPP include captopril, cinnarizine, ramipril, simvastatin, PUVA, and antituberculous medications. Nayak S, Acharjya B. 2. Antiepileptic medications, antihypertensive medications, antibiotics, calcium channel blockers and a variety of topical agents (Table 2)2,3,69 can cause exfoliative dermatitis, but theoretically, any drug may cause exfoliative dermatitis. Stern RS. Allergol Immunopathol (Madr). J Dermatol Sci. Article Half-life of the drug is approximately 54 h. Modification of nitisinone in liver and renal dysfunction is yet to be studied. A recently published meta-analysis by Huang [110] and coworkers on IVIG in SJS/SJS-TEN/TEN reviewed 17 studies with 221 patients and compared the results obtained with high-dosage IVIG (>2g/kg) compared to lower-dosage IVIG (<2g/kg). [117] described a cohort of ten patients affected by TEN treated with a single dose of etanercept 50mg sc with a rapid and complete resolution and without adverse events. Next vol/issue Br J Dermatol. Rzany B, et al. These levels could reflect the interaction between culprit drugs and aldehyde dehydrogenase that is the enzyme which metabolizes retinoid acid. A significant number of these patients eventually progress to cutaneous T-cell lymphoma.8, Clinically, the first stage of exfoliative dermatitis is erythema, often beginning as single or multiple pruritic patches, involving especially the head, trunk and genital region. Wetter DA, Davis MD. Since the earliest descriptions of exfoliative dermatitis, medications have been known to be important causative agents. N Engl J Med. A drug eruption may start as a rash but eventually progress to more generalized exfoliative dermatitis. Erythema multiforme (EM), StevensJohnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are the main clinical presentations of drug induced ED. 2010;85(2):1318. Huff JC, Weston WL, Tonnesen MG. Erythema multiforme: a critical review of characteristics, diagnostic criteria, and causes. Rheumatology (Oxford). Loss of normal vasoconstrictive function in the dermis, decreased sensitivity to the shivering reflex and extra cooling that comes from evaporation of the fluids leaking out of the weeping skin lesions all result in thermoregulatory dysfunction that can cause hypothermia or hyperthermia.6 The basal metabolic rate also is increased in patients with exfoliative dermatitis. The clinical course of patients with malignancies depends on the type of malignancy and the response to appropriate therapy. J Am Acad Dermatol. 2002;146(4):7079. (2.4, 5.6) Embryo-fetal Toxicity: Can cause fetal harm. Kano Y, et al. 2012;97:14966. Ann Allergy Asthma Immunol. Schwartz RA, McDonough PH, Lee BW. Br J Dermatol. In: Eisen AZ, Wolff K, editors. Erythema multiforme and latent herpes simplex infection. Mortality rate of patients with TEN has shown to be directly correlated to SCORTEN, as shown in Fig. Erythema multiforme (EM), Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are the main clinical presentations of drug induced ED. In case of a respiratory failure, oxygen should be administrated and a NIMV may be required. Chung WH, et al. 2012;166(2):32230. Huang YC, Li YC, Chen TJ. Unable to load your collection due to an error, Unable to load your delegates due to an error, Erythema multiforme (photo reproduced with permission of Gary White, MD): typical target lesions (, Mortality rate of patients with TEN has shown to be directly correlated to SCORTEN. Their occurrence can be prevented by avoiding drug over-prescription and drug associations that interfere with the metabolism of the most frequent triggers [118]. The dermo-epidermal junction and epidermis are infiltrated mostly by CD8+ T lymphocytes whereas dermal infiltrate, mainly made from CD4+ T lymphocytes, is superficial and mostly perivascular [20, 51]. Archivio Istituzionale della Ricerca Unimi, Nayak S, Acharjya B. 2012;12(4):37682. Stevens-Johnson syndrome and toxic epidermal necrolysis due to anticonvulsants share certain clinical and laboratory features with drug-induced hypersensitivity syndrome, despite differences in cutaneous presentations. Paul C, et al. Science. Mayes T, et al. Sekula P, et al. 1991;97(4):697700. Recurrent erythema multiforme: clinical characteristics, etiologic associations, and treatment in a series of 48 patients at Mayo Clinic, 2000 to 2007. . J Invest Dermatol. Perforin/granzyme B pathway: Nassif and colleagues have proposed a role for perforin/grazyme B in keratinocyte death [37]. Narita YM, et al. Patients who have exfoliative dermatitis of unknown cause tend to have an unpredictable course, usually replete with multiple remissions and exacerbations.4. Drugs such as paracetamol, other non-oxicam NSAIDs and furosemide, bringing a relatively low risk of SJS/TEN a priori, are also highly prevalent as putative culprit agents in large SJS/TEN registries, due to their widespread use in the general population [63, 64] (Table1). They usually have fever, are dyspneic and cannot physiologically feed. 2013;133(5):1197204. 2010;5:39. SSSS is characterized by periorificial face scabs, de-epithelialization of friction zones and conspicuous desquamation after initial erythroderma. Etanercept: monoclonal antibody against the TNF- receptor. In acute phase it is crucial to assess the culprit agent, in particular when the patient was assuming several drugs at time of DHR. Mockenhaupt M, et al. J Invest Dermatol. In addition to all these mechanisms, alarmins, endogenous molecules released after cell damage, were found to be transiently increased in SJS/TEN patients, perhaps amplifying the immune response, including -defensin, S100A and HMGB1 [47]. J Pharm Health Care Sci. The diagnosis of GVDH requires histological confirmation [87]. Article The team should include not only physicians but also dedicated nurses, physiotherapists and psychologists and should be instituted during the first 24h after patient admission. Erythema multiforme (EM), Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are the main clinical presentations of drug induced ED. doi: 10.4065/mcp.2009.0379. Trautmann A, et al. Toxic epidermal necrolysis: effector cells are drug-specific cytotoxic T cells. 2010;125(3):70310. Paquet P, et al. It was used with success in different case reports [114116]. Sokumbi O, Wetter DA. Frequently reported adverse events of rebamipide compared to other drugs for peptic ulcer and gastroesophageal reflux disease. Article 1998;282(5388):4903. Yacoub, MR., Berti, A., Campochiaro, C. et al. 2013;168(3):53949. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). The scales may be small or large, superficial or deep. An increased metabolism is typical of patients with extended disepithelizated areas. Gastrointestinal: pancreatitis, glossitis, dyspepsia. All non-indispensable drugs have to be stopped because they could alter the metabolism of the culprit agent. Plasmapheresis. Harr T, French LE. Ardern-Jones MR, Friedmann PS. Erythema multiforme (EM), Stevens- Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are the main clinical presentations of drug induced ED. HHS Vulnerability Disclosure, Help Utility of the lymphocyte transformation test in the diagnosis of drug sensitivity: dependence on its timing and the type of drug eruption. Schwartz RA, McDonough PH, Lee BW. 2010;88(1):608. The type of rash that happens depends on the medicine causing it and your response. Kostal M, et al. Patients can be extremely suffering because of the pain induced by skin and mucosal detachment. J Am Acad Dermatol. . Hospitalization and dermatologic consultation are indicated in most cases to ensure that all of the necessary cutaneous, laboratory and radiologic investigations and monitoring are performed. In fact, it was demonstrated that the specificity of the TCR is a required condition for the self-reaction to occur. If there is a high suspicion of infection without a documented source of infection, broad range empiric therapy should be started. 2013;69(2):1734. SCORTEN: a severity-of-illness score for toxic epidermal necrolysis. Erythema multiforme. Four main pathways have been found to play important roles in the pathogenesis of keratinocyte death: (1) Fas-FasL interaction, (2) Perforin/granzyme B pathway, (3) Granulysin and (4) Tumor necrosis factor (TNF-) [26]. Eur J Clin Microbiol Infect Dis. Fritsch PO. If cutaneous pathology also mimics cutaneous T-cell lymphoma, it can be very difficult to differentiate a drug-induced skin condition from exfoliative dermatitis associated with a malignancy.2,9. Rare dermatological side effects such as alopecia, exfoliative dermatitis, xeroderma, pruritus have been reported. 2013;27(5):65961. Oliveira L, Zucoloto S. Erythema multiforme minor: a revision. They found that the inhibition of these molecules could attenuate the cytotoxic effect of lymphocytes toward keratinocytes. Gastric protection. Patmanidis K, et al. Here we provide a systematic review of frequency, risk factors, molecular and cellular mechanisms of reactions, clinical features, diagnostic work-up and therapy approaches to drug induced ED. 2010;2(3):18994. Retrospective review of StevensJohnson syndrome/toxic epidermal necrolysis treatment comparing intravenous immunoglobulin with cyclosporine. Downey A, et al. Robyn A. McMenamin, L M. Davies and P. W. Craswell, Aust. The cutaneous T-cell lymphomas are the lymphomas most commonly associated with exfoliative dermatitis. The incidence of erythema multiforme, StevensJohnson syndrome, and toxic epidermal necrolysis. Int J Dermatol. Arch Dermatol. statement and Exfoliative dermatitis is a disease process in which most, and sometimes all, of the skin is involved in erythematous inflammation resulting in massive scaling.1 A variety of diseases and other exogenous factors may cause exfoliative dermatitis. In more severe cases corneal protective lens can be used. 1996;35(4):2346. Google Scholar. Analysis for circulating Szary cells may be helpful, but only if the cells are identified in unequivocally large numbers. Toxic epidermal necrolysis: Part I Introduction, history, classification, clinical features, systemic manifestations, etiology, and immunopathogenesis. Google Scholar. Unauthorized use of these marks is strictly prohibited. Exfoliative dermatitis accounts for about 1 percent of all hospital admissions for dermatologic conditions.3, Although the disease affects both men and women, it is more common in men, with an average male-to-female ratio of 2.3:1. Patient must be placed in an antidecubitus fluidized bed and room temperature must be kept at 3032C in order to slow catabolism and reduce the loss of calories through the skin [89]. 2002;65(9):186170. Exfoliative dermatitis is characterized by generalized erythema with scaling or desquamation affecting at least 90% of the body surface area.

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