Erythema is a generalized diffuse inflammation of the skin, accompanied by hyperemia and edema of the dermis, rash of papules, bullae and pustules, which erode with the formation of crusts and peeling, tend to merge and peripheral growth. Spreading, the foci of inflammation capture all new areas of the dermis, there is a lesion of hair and nails. Rashes are accompanied by prodroma, itching, cracking, and the addition of a secondary infection. Disease is diagnosed clinically and based on laboratory tests. Inpatient treatment includes antibiotics, glucocorticoids, immunomodulators, antihistamines and other drugs.
L53.9 Erythematous condition, unspecified
Erythema is an almost total inflammation of the epidermis, which is a symptom of a number of peeling dermatoses of various etiologies and malignant hemoderma or (less often) occurs against the background of previously unchanged skin. Poses a danger to the patient’s life. The frequency of deaths in erythema, according to various authors, ranges from 18% to 64%. When disease is associated with skin cancer or malignant lymphoma of the skin, mortality is determined by the severity of the underlying disease.
In USA dermatology, the pathological process is recorded in 1-2% of cases of all hospitalizations of patients with skin lesions. According to foreign experts, erythema occurs in 0.07% of cases of skin pathology. Disease affects patients older than 40-60 years, and men are 2-4 times more likely than women, which is probably due to the greater prevalence of bad habits and diseases provoked by them with damage to the immune system among males. The pathological process debuts at any time of the year, it is not endemic. The urgency of the problem is related to the severity of the course, the possibility of a fatal outcome.
Erythema is polyetiological because it unites a whole group of pathologies. Primary form is spontaneous. Secondary form is a symptom of various dermatoses (psoriasis, eczema, etc.). The most likely triggers of the pathological process are genetic mutations and disorders in the immune system.
The pathogenesis of the disease has not been sufficiently studied, while it remains unclear why such different causes cause the same pathological response of the skin. Nevertheless, experts in the field of dermatology believe that the pathogenesis of erythema resembles the development of a “graft versus host” reaction. When introduced into the human body, foreign antigens meet with tissue compatibility antigens HLA – protein molecules on the surface of each human cell. The HLA kit is individual for each patient. Tissue compatibility antigens catch “strangers” and filter them, separating them from the body’s own cells.
HLA are associated with the genes of the main histocompatibility complex of the 6th chromosome, therefore they are the first to react to any genetic mutations. The HLA system regulates the immune response by transmitting a “stranger” to T-lymphocytes, recognizing the body’s own cells into which a foreign antigen has managed to penetrate, activating cellular and humoral immunity to destroy antigens. It also controls the immune response to inflammation that develops in the dermis when skin cells are damaged. Pathogens damage the keratinocytes of the epidermis, which begin the production of pro-inflammatory cytokines. HLA transmits pathogens to T-lymphocytes, activating immunity and the production of T-killers and T-suppressors.
The HLA-activated immune system additionally produces cytotoxic T-lymphocytes, which also destroy foreign antigens. At the same time, the cytokine profile of the immune response in erythema includes TH1 and TH2, which makes it possible to neutralize antigens of various origins. TH1 cells destroy the infectious origin, and TH2 cells synthesize interleukins, which enhance the proliferation and formation of IgE class antibodies responsible for allergic reactions.
Such a powerful response is clinically manifested by erythema of the skin. The proliferation processes accompanying antigenic aggression have their own peculiarity – the mitotic activity of the basal cells of the epidermis increases sharply, their transportation to the surface of the dermis. Clinically, there is a large-plate peeling characteristic of erythema.
The classification of erythema was proposed by the French dermatologist Louis Brock at the beginning of the last century. He divided all variants of diffuse inflammation of the skin into three groups: primary (spontaneously arising on unchanged dermis), secondary (developing against the background of dermatoses of various etiologies) and erythema, which are a symptom of malignant hemoderma. This classification is still relevant, but today dermatologists distinguish, first of all, benign and malignant pathology in order to prescribe adequate therapy in a timely manner.
Among the secondary benign erythema are:
- Psoriatic erythema accompanying severe forms of psoriasis. It is divided into a generalized form with an almost total lesion of the skin, a hyperergic form with a tendency to peripheral growth of foci of inflammation and prodroma, a suppurating form – transitional between pustular psoriasis of Tsumbush and true erythema.
- Ichthyosiform erythema, which can be bullous, nebulous and lamellar.
- Broca’s erythema, congenital dermatosis with universal hyperkeratosis.
- Erythema Leiner-Moussa, desquamative dermatosis of newborns.
- Eczematous erythema, which is a symptom of a severe course of the eczematous process.
- Exfoliative erythema (generalized exfoliative dermatitis) is the most severe type of erythematous process.
- Deverji’s disease is an erythrodermic form characterized by foci of flaky erythema.
- Drug erythema is the result of irrational therapy.
Among the secondary malignant erythema, there are:
- Erythema – one of the forms of T-cell lymphoma with total redness of the skin and abundant large-plate peeling.
- Cesari syndrome is erythrodermic reticulosis with reticulemia.
Erythema can occur spontaneously, acutely, for no apparent reason, or make its debut against the background of the progression of a long-existing dermatosis. However, with any variant in the clinical picture of erythema, two stages of the development of the pathological process can be distinguished. At the initial stage, there is a rash of primary elements in the form of bullae, papules, pustules against the background of hyperemia and the predominance in some cases of exudative processes with swelling of the skin. Over time, the epidermis becomes thinner.
Primary eruptions are involuted, but new ones are poured in parallel. Pustules and vesicles are opened with the formation of erosions, which are covered with hemorrhagic or purulent crusts. The primary elements in erythema have peripheral growth, a tendency to merge and the formation of foci of inflammation of considerable size, which very quickly capture new areas of the skin up to its total lesion. It should be noted that spontaneous resolution of erythema is possible at the initial stage.
In the folds of the skin, wetness begins, a secondary infection joins. The entire affected skin is peeling off in large plates. Rashes are accompanied by subjective sensations: soreness, burning of the skin, severe itching, general weakness, bruising, arthralgia. Body temperature rises to subfebrile digits. There is an exacerbation of concomitant diseases.
The secondary stage of erythema is characterized by thickening of the epidermis, involvement of mucous membranes, hair and nails in the process. Hair falls out, alopecia progresses, nails dystrophically change, exfoliate, break. There are increasing symptoms of intoxication: tachycardia, chills, muscle trembling, high (sometimes up to 40 °C) fever, enlargement of lymph nodes, liver and spleen, dyspepsia, breast swelling. All this requires urgent exclusion of the malignancy of the process, the adoption of emergency therapeutic measures.
A clinical diagnosis is made by a dermatologist based on anamnesis, symptoms, laboratory tests and additional research methods. During the examination, the cause of the development of the disease (inflammation or malignant process) is specified. A single skin biopsy is 50% uninformative, so a series of biopsies is performed if necessary.
To detect signs of malignancy, the T-cell receptor gene is re-angled by electrophoresis in agar-agar gel (determination of a certain DNA sequence in the tissue sample under study) and peripheral blood smears. Immunohistochemistry is used, the determination of monoclonal antibodies. HIV testing is used, the levels of lipids, zinc, amino acids are examined in children. Differentiate erythema with the following diseases:
- actinic, seborrheic and atopic dermatitis;
- red hair and flat lichen;
- common psoriasis;
- lymphoproliferative processes.
The therapy plan is made taking into account the cause of the development and form of the disease. The treatment is complex, carried out in stationary conditions. Glucocorticosteroids, cytostatics, antibiotics, antihistamines, enterosorbents, immunomodulators are used, most often in the form of intravenous infusions. Contact with water is excluded, since moisture provokes the spread of the process. Sometimes extracorporeal hemocorrection, photochemotherapy are prescribed. Externally, anti-inflammatory and emollient ointments are used.
The prognosis depends on the form of the disease and the timely start of therapeutic measures. In case of late diagnosis and treatment, a fatal outcome is possible, especially if erythema accompanies a malignant tumor process or systemic pathology.