Suspected erythroderma (adult)
Erythema with or without scaling over more than 90% of the body surface. Adult pathway. Child or neonate: get paediatric dermatology advice.
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DermatologyEmergency
Erythroderma (Exfoliative Dermatitis) Emergency Management
Erythroderma (Exfoliative Dermatitis) Emergency Management: Suspected erythroderma (adult) → Red flags: escalate to HDU or ICU → Stabilise: fluids, warm...
Pathway Overview
18 steps
Algorithm Steps
18 total
01Start 02Warning Red flags: escalate to HDU or ICU
Erythroderma can cause skin failure: fluid, heat and protein loss, and infection. Admit most patients.
- Shock, sepsis or suspected bacteraemia: sepsis pathway now. On long-term oral corticosteroid: also hydrocortisone 100 mg IV or IM now (adult)
- Hypothermia, high-output heart failure or acute kidney injury
- Severe electrolyte disturbance (Na, K, Ca, PO4) or low albumin with oedema
03Action Stabilise: fluids, warmth, skin barrier
Replace losses. Heart failure or older patient: give small fluid boluses and reassess often, because overload is a risk.
- IV access; fluids guided by BP, urine output, weight and electrolytes
- Keep warm (warm room, blankets); monitor core temperature
- Bland emollient (for example white soft paraffin) often; wet dressings. Fire risk: no smoking or naked flames (residue on dressings and bedding)
- Check and replace Na, K, Mg, Ca and PO4; check albumin
- Dietitian: high-energy, high-protein diet
- Stop non-essential drugs; do not stop long-term oral corticosteroids abruptly
04Warning Exclude SJS/TEN, DRESS and SSSS before any systemic steroid
These need their own pathway.
- Skin pain, blisters, skin detachment or mucosal erosions: SJS/TEN pathway
- Fever, facial oedema, lymphadenopathy, eosinophilia or abnormal LFTs 2 to 8 weeks after a new drug: DRESS pathway
- Tender skin with superficial peeling, mucosa spared (young child, or adult with renal failure or immunosuppression): SSSS pathway; no systemic corticosteroids
05Action Focused history
Look for the cause and for triggers.
- Known psoriasis, eczema or atopic dermatitis
- All drugs started in the past 2 months, including over-the-counter and herbal
- Recent stop of oral corticosteroids or ciclosporin (can trigger erythrodermic psoriasis)
- Weight loss, night sweats, lymphadenopathy (lymphoma)
- Itch in contacts or residential care (crusted scabies); HIV risk
- Could the patient be pregnant?
06Action Investigations
Often no cause is found at first. Repeat biopsy if the first is not diagnostic.
- FBC and blood film (eosinophils, Sezary cells)
- UEC, Ca, Mg, PO4, LFTs, albumin, CRP
- Febrile or unwell: blood cultures and skin swabs
- Skin biopsies from 2 to 3 sites; direct immunofluorescence if blistering
- Blood flow cytometry for Sezary cells if lymphoma possible
- Skin scrapings for scabies and fungi; HIV serology; pregnancy test if could be pregnant
07Action Skin care and monitoring (all causes)
Continue while the cause is found and treated.
- Low- to mid-potency topical corticosteroid with wet dressings. Crusted scabies or tinea suspected: no topical corticosteroid until excluded (worsens them)
- Sedating antihistamine at night may help itch; caution in older adults (falls, delirium)
- Daily weight, fluid balance, temperature and electrolytes
- VTE prophylaxis if admitted and no contraindication
08Warning Watch for secondary infection and sepsis
Broken skin barrier: Staphylococcus aureus is the most common cause. On methotrexate: avoid trimethoprim and co-trimoxazole. On acitretin: avoid tetracyclines. Eczema with punched-out erosions: eczema herpeticum pathway.
- Fever or hypothermia, pustules, crusting or rising CRP: blood cultures and skin swabs
- Start an anti-staphylococcal antibiotic (for example flucloxacillin). MRSA risk, or immediate or severe penicillin allergy: vancomycin. Low-risk penicillin allergy: cefazolin
- Suspected culprit drug is an antibiotic: use a different class
09Decision Most likely cause?
Treat the cause with a dermatologist. Most common: eczema, psoriasis, atopic dermatitis, drug eruption and CTCL. Often no cause is found.
- Psoriasis
10Warning Psoriasis: pregnancy, kidney, liver, infection and CTCL checks first
Known psoriasis with generalised flare: erythrodermic psoriasis. Check these before any systemic drug. Severe liver disease or alcohol excess: no methotrexate or acitretin. Low blood counts: no methotrexate. Cancer other than skin: no ciclosporin.
- Could be pregnant or breastfeeding: pregnancy test; no methotrexate or acitretin
- Abnormal kidney function, uncontrolled BP or active infection: no ciclosporin; no methotrexate in severe kidney impairment or severe infection
- CTCL not yet excluded: no ciclosporin (can worsen lymphoma)
11Action Erythrodermic psoriasis: systemic therapy
Dermatologist chooses. Avoid systemic corticosteroids: high risk of rebound flare on withdrawal.
- Unstable or severe: ciclosporin, or a fast-acting biologic
- Ciclosporin (adult, oral): 2.5 to 5 mg/kg/day in 2 divided doses; max 5 mg/kg/day
- Before ciclosporin: creatinine twice and BP; cut dose by 25 to 50% if creatinine stays over 30% above baseline
- Biologic (IL-17 inhibitor, risankizumab or infliximab): screen TB, hepatitis B and C, and HIV first
- Stable: methotrexate (once weekly only) or acitretin
- Acitretin: contraception from 1 month before to 3 years after; never with methotrexate or tetracyclines
- Drug
12Action Recent new drug: drug-induced erythroderma
Stop the suspected drug now. Record it as an allergy and report it to the TGA.
- Common culprits: allopurinol, anticonvulsants (carbamazepine, phenytoin), sulfonamides, beta-lactams, calcium channel blockers
- DRESS features (fever, eosinophilia, organ involvement): DRESS pathway
- Otherwise: supportive care and topical corticosteroid
- Systemic corticosteroid only on dermatologist advice, after SJS/TEN, SSSS and infection are excluded
- CTCL
13Warning Sezary cells or suspected lymphoma: CTCL
Cutaneous T-cell lymphoma (Sezary syndrome) can present as erythroderma.
- Refer to haematology and dermatology; repeat skin biopsies and blood flow cytometry
- Do not give ciclosporin (can worsen lymphoma)
- Treatment is specialist-led (for example phototherapy or systemic therapy)
- Other dermatosis
14Action Other dermatosis found: treat the cause
Dermatologist-led treatment of the underlying disease.
- Atopic dermatitis or eczema: topical corticosteroid and wet dressings; systemic agent (for example dupilumab or ciclosporin) by dermatologist after CTCL is excluded
- Pityriasis rubra pilaris: acitretin by dermatologist; not in pregnancy; contraception until 3 years after
- Pemphigus foliaceus: systemic corticosteroid with or without rituximab, dermatologist-led
- Crusted scabies: contact precautions; oral ivermectin plus topical permethrin (infectious diseases advice)
- Contact dermatitis: remove the allergen
- Seborrhoeic dermatitis: topical antifungal
- No cause found
15Action Cause not found: treat as idiopathic
Continue supportive skin care. Keep looking for lymphoma.
- Topical corticosteroid, emollients and wet dressings
- Persistent: repeat skin biopsies and blood flow cytometry for CTCL
- Systemic therapy only by a dermatologist, after CTCL is excluded
- All causes: daily review
16Decision All causes: improving on treatment?
Review daily whatever the cause: skin, fluid balance, temperature, electrolytes and infection.
- If Yes
17Outcome Improving: continue treatment and plan follow-up
Improvement is gradual over weeks. Continue treatment of the cause; dermatology follow-up.
- Continue treatment of the cause
- Dermatology follow-up before discharge
- Long-term maintenance therapy may be needed
If No18Warning Not improving or worse: escalate and re-investigate
Unstable, septic or in heart failure: HDU or ICU.
- Repeat skin biopsies and blood flow cytometry (CTCL, other causes)
- Review all drugs again for a culprit
- Look again for infection and sepsis
Guideline Source
Erythroderma: a dermatologic emergency (Bruno and Grewal, CJEM 2009)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- No formal erythroderma guideline exists; content is based on reviews, the NPF 2010 consensus with a 2025 systematic review (psoriasis) and Australian product information
- Adults only; systemic therapy must be chosen by a dermatologist, and early biopsies often do not show the cause
- Erythroderma can be the first sign of cutaneous T-cell lymphoma
- Doses and drug choices do not cover pregnancy, breastfeeding or children
Contraindicated Populations
Children and neonates (causes and treatment differ; get paediatric dermatology advice)
Applicable Regions
AUUSEU
AU: TGA pregnancy categories: acitretin X (Neotigason PI: contraception until 3 years after stopping), methotrexate D, ciclosporin C. Report suspected drug reactions to the TGA.
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Erythroderma (Exfoliative Dermatitis) Emergency Management?
The Erythroderma (Exfoliative Dermatitis) Emergency Management is a emergency clinical algorithm for Dermatology. It provides a structured decision tree to guide clinical decision-making, based on Erythroderma: a dermatologic emergency (Bruno and Grewal, CJEM 2009).
What guideline is the Erythroderma (Exfoliative Dermatitis) Emergency Management based on?
This algorithm is based on Erythroderma: a dermatologic emergency (Bruno and Grewal, CJEM 2009) (DOI: 10.1017/S1481803500011283).
What are the limitations of the Erythroderma (Exfoliative Dermatitis) Emergency Management?
Known limitations include: No formal erythroderma guideline exists; content is based on reviews, the NPF 2010 consensus with a 2025 systematic review (psoriasis) and Australian product information; Adults only; systemic therapy must be chosen by a dermatologist, and early biopsies often do not show the cause; Erythroderma can be the first sign of cutaneous T-cell lymphoma; Doses and drug choices do not cover pregnancy, breastfeeding or children. Individual patient factors may require deviation from these recommendations.
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