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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Erythroderma is the clinical finding of generalized erythema and scaling of the skin&#46; This condition&#44; especially when fulminant&#44; is potentially life-threatening and has been associated with high mortality in hospitalized patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0505"><span class="elsevierStyleSup">1&#44;2</span></a> The term erythroderma was first used by Ferdinand Von Hebra in 1868 in his work &#8220;On Diseases of the Skin&#8221; to describe generalized skin redness and scaling&#46;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">3</span></a> A variety of diseases and exogenous factors can cause this syndrome&#46; Although rare&#44; it remains a relevant and difficult for dermatologists to treat this disease&#46; The objective of this article is to review the general principles&#44; the clinical aspects and the pathogenesis of erythroderma in adults&#44; as well as to provide a concise guide for its diagnostic and therapeutic approach&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Definition</span><p id="par0010" class="elsevierStylePara elsevierViewall">Erythroderma also called generalized exfoliative dermatitis or exfoliative erythroderma&#44; is a severe inflammatory skin syndrome characterized by generalized erythema and desquamation comprising &#8805; 90&#37; of the body surface area&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">4</span></a> Generally&#44; erythroderma is the preferred term for this syndrome&#46;<a class="elsevierStyleCrossRefs" href="#bib0520"><span class="elsevierStyleSup">4&#44;5</span></a> Previously&#44; some authors used the term &#8220;red man syndrome&#8221; to refer to idiopathic erythroderma &#40;which must not be confused with the cutaneous reaction associated to rapid intravenous infusion of vancomycin&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">6</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Epidemiology</span><p id="par0015" class="elsevierStylePara elsevierViewall">Erythroderma is a rare condition&#46; Most published studies are retrospective and do not address overall incidence&#46;<a class="elsevierStyleCrossRefs" href="#bib0535"><span class="elsevierStyleSup">7&#44;8</span></a> A retrospective study from China reported that erythroderma accounted for 13 of every 100&#44;000 dermatologic patients&#46;<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">9</span></a> Recently&#44; an incidence of 9&#46;4 cases&#47;year was reported in a retrospective study from Portugal&#46;<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">10</span></a> Excluding children&#44; the average age of onset varies from 41 to 61 years&#59; although it usually affects patients over 45 years of age&#46;<a class="elsevierStyleCrossRefs" href="#bib0555"><span class="elsevierStyleSup">11&#44;12</span></a> Studies favor a male predominance with a male-to-female ratio of 2-4&#58;1&#46;<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">13</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pathogenesis</span><p id="par0020" class="elsevierStylePara elsevierViewall">Implicated fisiopathogenic mechanisms depend upon the underlying cause&#46; Common pathogenic pathways among different etiologies are still a question of debate&#46;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">6</span></a> It is believed that this syndrome derives from a complex interaction between cytokines and cellular adhesion molecules&#46; IL-1&#44; IL-2&#44; IL-8&#44; intercellular adhesion molecule 1 &#40;ICAM-1&#41;&#44; tumor necrosis factor and interferon gamma have all been involved in the pathogenesis of erythroderma&#46;<a class="elsevierStyleCrossRefs" href="#bib0520"><span class="elsevierStyleSup">4&#44;7&#44;8</span></a> Interactions between these cytokines result in an increased epidermal cellular division&#46; This increased mitotic rate shortens the transit time of cells through the epidermis&#44; thus resulting in cutaneous exfoliation&#46; Scales are normally retained by the skin and contain amino acids&#44; proteins and nucleic acids which are lost during desquamation&#46;<a class="elsevierStyleCrossRefs" href="#bib0570"><span class="elsevierStyleSup">14&#44;15</span></a> It has been calculated that this desquamative process may increase protein loss by 25-30&#37; in psoriatic erythroderma and by 10-15&#37; in other causes&#46;<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">15</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Etiology</span><p id="par0025" class="elsevierStylePara elsevierViewall">Erythroderma represents a final clinical endpoint for many dermatological diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">16</span></a> As observed in a recent retrospective study&#44; the relative incidence of different etiologies may vary among populations due to genetic&#44; geographic&#44; and social disparities&#46;<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">10</span></a> Most studies indicate that erythroderma is more commonly associated with an exacerbation of a pre-existing dermatosis&#59; therefore&#44; the patient&#39;s medical history is crucial for a correct diagnosis&#46; Psoriasis is the most frequent cause of exfoliative dermatitis&#44; which in some studies represents 25-50&#37; of cases &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0550"><span class="elsevierStyleSup">10&#44;17&#8211;19</span></a> Most patients have a history of localized disease before the onset of exfoliative dermatitis&#44; which develops more frequently with long-standing psoriasis &#40;more than 10 years after diagnosis&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0545"><span class="elsevierStyleSup">9&#44;10&#44;20&#44;21</span></a> Psoriatic erythroderma has been associated with certain triggers&#44; including the sudden withdrawal of topical or systemic corticosteroids and methotrexate&#44; phototoxicity&#44; or systemic infection&#46;<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">22</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">It has been reported that exfoliative dermatitis related to atopic dermatitis varies from 4&#46;76 to 23&#46;9&#37; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0595"><span class="elsevierStyleSup">19&#44;23</span></a> A history of non-atopic eczema has been found in 5&#46;12&#37; to 25&#46;3&#37; of patients with erythroderma&#46;<a class="elsevierStyleCrossRefs" href="#bib0620"><span class="elsevierStyleSup">24&#8211;26</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">In case series&#44; drug-related reactions represent the second most frequent cause of erythroderma&#44; ranging from 11&#46;3 to 21&#46;6&#37; of cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0545"><span class="elsevierStyleSup">9&#44;10&#44;20</span></a> The list of drugs that cause erythroderma is long and continuously grows&#46; Previous authors have reported that drugs with the greatest erythroderma-inducing potential are anti-epileptic medications and allopurinol&#46;<a class="elsevierStyleCrossRefs" href="#bib0545"><span class="elsevierStyleSup">9&#44;10&#44;20&#44;22</span></a> Carbamazepine is the most common anti-epileptic drug related to this syndrome and it has been postulated that this may be a result of genetic sensitivity or its frequent prescription&#46;<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">11</span></a>Antifimic drugs have been associated with erythroderma in HIV-seropositive patients&#44;<a class="elsevierStyleCrossRefs" href="#bib0635"><span class="elsevierStyleSup">27&#44;28</span></a> as well as with traditional Chinese herbs used as analgesics&#46;<a class="elsevierStyleCrossRefs" href="#bib0545"><span class="elsevierStyleSup">9&#44;29</span></a> Other common drugs related to this condition are phenytoin&#44; beta-lactam antibiotics&#44; sulfonamides&#44; phenobarbital&#44; sulfasalazine and proton pump inhibitors&#46;<a class="elsevierStyleCrossRefs" href="#bib0550"><span class="elsevierStyleSup">10&#44;30</span></a> Non-ionic contrast material has also been reported as an inducer of this syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0655"><span class="elsevierStyleSup">31</span></a> Exfoliative dermatitis has been related to a severe form of pityriasis rubra pilaris in 1&#46;25&#37; to 8&#46;2&#37; of cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0555"><span class="elsevierStyleSup">11&#44;24</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Most series report 1&#37; of erythroderma cases have a neoplasic or paraneoplastic etiology&#46;<a class="elsevierStyleCrossRefs" href="#bib0540"><span class="elsevierStyleSup">8&#44;23&#44;32&#44;33</span></a> It has been implicated in laryngeal&#44; thyroid&#44; breast&#44; lung&#44; esophageal&#44; gastric&#44; hepatocellular&#44; tongue&#44; gallbladder&#44; colon&#44; fallopian tube and prostate cancers&#46;<a class="elsevierStyleCrossRefs" href="#bib0520"><span class="elsevierStyleSup">4&#44;9&#44;34&#8211;42</span></a> But it is more often related to hematologic malignancies and cutaneous T-cell lymphomas&#44; which constitute 25 to 40&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">4</span></a> Within this subgroup&#44; mycosis fungoides &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#44; and S&#233;zary syndrome are more frequent&#46;<a class="elsevierStyleCrossRefs" href="#bib0715"><span class="elsevierStyleSup">43&#44;44</span></a> Acute and chronic leukemia&#44; reticular cell sarcoma&#44; and malignant histiocytosis have also been implicated&#46;<a class="elsevierStyleCrossRefs" href="#bib0550"><span class="elsevierStyleSup">10&#44;45&#44;46</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">In 6&#46;51&#37; to 36&#37; of patients&#44; no precise etiology can be identified&#46;<a class="elsevierStyleCrossRef" href="#bib0735"><span class="elsevierStyleSup">47</span></a> Some authors have described the progression of chronic idiopathic erythroderma to cutaneous T-cell lymphoma&#46;<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">19</span></a> Uncommon causes of adult exfoliative dermatitis include congenital icthyoses&#44;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">6</span></a> staphylococcal scalded skin syndrome&#44;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">6</span></a> immunobullous diseases&#44;<a class="elsevierStyleCrossRef" href="#bib0740"><span class="elsevierStyleSup">48</span></a> connective tissue diseases such as dermatomyositis&#44;<a class="elsevierStyleCrossRef" href="#bib0745"><span class="elsevierStyleSup">49</span></a> chronic actinic dermatitis&#44;<a class="elsevierStyleCrossRef" href="#bib0750"><span class="elsevierStyleSup">50</span></a> sarcoidosis&#44;<a class="elsevierStyleCrossRef" href="#bib0755"><span class="elsevierStyleSup">51</span></a> Norwegian scabies&#44;<a class="elsevierStyleCrossRef" href="#bib0760"><span class="elsevierStyleSup">52</span></a> Langerhans cell histiocytosis&#44;<a class="elsevierStyleCrossRef" href="#bib0765"><span class="elsevierStyleSup">53</span></a> irradiation&#44; graft-vs-host disease&#44; Ofuji papulo-erythroderma and Omenns&#8217; syndrome&#46;<a class="elsevierStyleCrossRefs" href="#bib0590"><span class="elsevierStyleSup">18&#44;54&#8211;58</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Clinical Manifestations</span><p id="par0050" class="elsevierStylePara elsevierViewall">Erythroderma has a gradual and insidious onset except for drug-induced cases&#46;<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">24</span></a> This condition begins as patches of erythema that enlarge and coalesce to eventually affect most of the skin surface&#46; It is associated with a variable degree of scaling that typically appears 2-6 days after the onset of erythema&#46; The skin is usually bright red&#44; dry&#44; warm and indurated&#46; Most patients complain of skin pain or pruritus&#46; In acute phases&#44; scales may appear large and crusted&#44; whereas in chronic states they tend to be smaller and drier&#46;<a class="elsevierStyleCrossRefs" href="#bib0520"><span class="elsevierStyleSup">4&#44;12</span></a> The type of scale may suggest the underlying etiology&#58; fine scales are usually found in eczematous conditions&#44; crusted scales in immunobullous diseases&#44; exfoliative scales in drug reactions and bran-like scales in seborrheic dermatitis&#46;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">6</span></a> In chronic erythroderma&#44; patients may develop crusted erosions and secondary lichenification because of severe scratching&#59; hyper- or hypopigmentation may also be present&#46; Nails may become thick&#44; dry&#44; brittle&#44; shiny&#44; and show ridging&#46;<a class="elsevierStyleCrossRefs" href="#bib0520"><span class="elsevierStyleSup">4&#44;12</span></a> A recent clinical study by Mahabaleshwar et al&#46; reported the following nail changes in erythroderma patients&#58; discoloration &#40;40&#37;&#41;&#44; ridges &#40;36&#37;&#41;&#44; pitting &#40;20&#37;&#41;&#44; onycholysis &#40;18&#37;&#41;&#44; shiny nails &#40;4&#37;&#41; and paronychia &#40;2&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">20</span></a> Palmoplantar keratoderma appears in approximately 30&#37; of patients&#46; Classically&#44; marked keratoderma is associated with pityriasis rubra pilaris&#44; yet some reports have found that palmoplantar keratoderma and nail changes are predictive clinical signs of psoriasis&#46;<a class="elsevierStyleCrossRefs" href="#bib0530"><span class="elsevierStyleSup">6&#44;9&#44;10&#44;22&#44;25</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Rare hematologic syndromes may mimic clinical manifestations of erythrodermic psoriasis such as idiopathic hypereosinophilic syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0795"><span class="elsevierStyleSup">59</span></a> Pityriasis rubra pilaris typically shows islands of sparing&#44; orange-colored palmoplantar keratoderma and hyperkeratotic follicular papules on extensor surfaces&#46;<a class="elsevierStyleCrossRef" href="#bib0800"><span class="elsevierStyleSup">60</span></a> Violaceous papules and reticulated buccal mucosal lesions may indicate an underlying diagnosis of lichen planus&#46;<a class="elsevierStyleCrossRef" href="#bib0805"><span class="elsevierStyleSup">61</span></a> Patients with Norwegian scabies may develop heavy crusts on the palms and soles&#44; as well as subungual hyperkeratosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0760"><span class="elsevierStyleSup">52&#44;60</span></a> Gottron&#39;s papules&#44; heliotrope rash&#44; poikiloderma&#44; periungual telangiectasias and muscle weakness may support the diagnosis of erythrodermic dermatomyositis&#46;<a class="elsevierStyleCrossRefs" href="#bib0810"><span class="elsevierStyleSup">62&#44;63</span></a> Moist and crusted lesions on the face and upper trunk can be an early manifestation of pemphigus foliaceous&#46; Non-scarring alopecia may appear in 20&#37; of patients with chronic erythroderma&#44; and ocular complications such as bilateral ectropion and purulent conjunctivitis may be particularly prominent in chronic erythroderma secondary to S&#233;zary syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">6</span></a> Some studies have described sparing of the nose and paranasal areas&#44; described as the &#8220;nose sign&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0820"><span class="elsevierStyleSup">64</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Systemic Manifestations</span><p id="par0060" class="elsevierStylePara elsevierViewall">Patients suffering exfoliative dermatitis will often shiver and complain of feeling cold&#46; A recent literature analysis by Cesar et al&#46; established pruritus as the most common symptom&#46;<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">10</span></a> Generalized peripheral lymphadenopathy may be present&#44; prompting histologic and molecular examination to rule out hematologic malignancy&#46; Other features described in this condition include facial&#44; pedal or pretibial edema&#44; hypothermia&#44; cachexia&#44; hepatomegaly&#44; splenomegaly&#44;<a class="elsevierStyleCrossRefs" href="#bib0530"><span class="elsevierStyleSup">6&#44;10</span></a> and fever in about half of the patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0550"><span class="elsevierStyleSup">10&#44;29</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The clinician must be aware of systemic manifestations that could potentially complicate disease evolution&#46; Exfoliative dermatitis may lead to systemic complications including fluid and electrolyte imbalance&#44; high-output cardiac failure&#44; acute respiratory distress syndrome&#44; and secondary infections &#40;erythrodermic skin is commonly colonized by <span class="elsevierStyleItalic">Staphylococcus aureus</span>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0530"><span class="elsevierStyleSup">6&#44;13&#44;65&#8211;67</span></a> Staphylococcal sepsis may occur due to inflamed and excoriated skin&#44; especially in HIV-positive patients or with an underlying hematological malignancy&#46;<a class="elsevierStyleCrossRefs" href="#bib0840"><span class="elsevierStyleSup">68&#44;69</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Histopathology</span><p id="par0070" class="elsevierStylePara elsevierViewall">In erytrhodermic patients clinical and histopathological correlation can be difficult to attain&#44;<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">24</span></a> yet highly trained pathologists can provide a precise diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">10</span></a> Skin samples are usually obtained with 4<span class="elsevierStyleHsp" style=""></span>mm punch biopsies and previous series report that multiple biopsies over time can enhance diagnostic accuracy&#46;<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">13</span></a> Previous studies report skin biopsies to be useful in 53-66&#37; of erythroderma cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0550"><span class="elsevierStyleSup">10&#44;70&#44;71</span></a> Frequent histopathologic findings in erythroderma include hyperkeratosis&#44; acanthosis&#44; spongiosis&#44; and perivascular inflammatory infiltrate&#46;<a class="elsevierStyleCrossRef" href="#bib0860"><span class="elsevierStyleSup">72</span></a> A recent retrospective study by Megna et al&#46; on 82 erythrodermic patients reported a diagnosis of psoriasis in 23&#46;2&#37; of subjects&#44; strongly supported by the presence of acanthosis&#44; diffuse parakeratosis&#44; diffuse hypogranulosis and the presence of neutrophils on epidermis and dermis&#46; Spongiotic dermatitis was found in 20&#46;7&#37; of patients&#59; encountered features included exocytosis&#44; superficial lymphocytic infiltrate&#44; spongiosis&#44; irregular acanthosis and dermal eosinophilic infiltrate&#46; Drug-induced erythroderma was diagnosed in 8&#46;5&#37; of subjects with biopsies showing lymphocytes and colloid bodies&#44; in addition to hydropic degeneration within the epidermal basal layer&#46; Cutaneous T-cell lymphoma &#40;CTCL&#41;&#47;mycosis fungoides &#40;8&#46;5&#37; in this study&#41; biopsies showed lymphocytic microabscesses&#44; in addition to epidermal and dermal atypical lymphocytes&#46; It is important to highlight that in a considerable number of cases &#40;39&#46;1&#37;&#41;&#44; the diagnosis was inconclusive not matching the final diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0865"><span class="elsevierStyleSup">73</span></a> These results support the fact that skin biopsies are a mandatory first step in the required workup of erythrodermic patients&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The majority of studies report that nodal biopsies frequently demonstrate dermatopathic lymphadenopathy&#44;<a class="elsevierStyleCrossRefs" href="#bib0550"><span class="elsevierStyleSup">10&#44;29&#44;74</span></a> yet lymph node biopsies may be the key to diagnostic exclusion of lymphomas or uncommon diseases such as multicentric Castleman&#39;s disease&#46;<a class="elsevierStyleCrossRef" href="#bib0875"><span class="elsevierStyleSup">75</span></a> The presence of atypical lymphocytes should prompt immunohistochemistry and T-cell receptor gene rearrangement studies&#46; S&#233;zary syndrome is supported by the presence of T-cells lacking mature T-cell antigens &#40;CD3<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>&#44; CD4<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>&#44; CD7-&#41; and T-cell receptor gene clonality&#46;<a class="elsevierStyleCrossRef" href="#bib0880"><span class="elsevierStyleSup">76</span></a> Immunofluorescence should be considered if histopathology suggests immunobullous disease&#44; graft-vs-host disease&#44; and connective tissue disorders&#46;<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">26</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Laboratory and Imaging</span><p id="par0080" class="elsevierStylePara elsevierViewall">Laboratory findings of erythrodermic patients are frequently nonspecific&#46; Common laboratory abnormalities described in previous studies &#40;in order of frequency&#41; include an elevated erythrocyte sedimentation rate &#40;96&#46;1&#37;&#41;&#44; leukocytosis &#40;48&#46;5&#37;&#41;&#44; eosinophilia &#40;39&#46;8&#37;&#41;&#44; and anemia &#40;30&#46;1&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">10</span></a> Allergic conditions may present increased serum IgE&#46; When suspecting drug-induced erythroderma&#44; the eosinophil count is necessary in DRESS syndrome&#46;<a class="elsevierStyleCrossRefs" href="#bib0535"><span class="elsevierStyleSup">7&#44;33&#44;49&#44;77&#44;78</span></a> A recent study found a correlation between the presence of eosinophilia and malignancy-related erythroderma&#46;<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">10</span></a> Other findings include elevated uric acid and creatinine levels&#44; as well as reduced serum protein levels&#46;<a class="elsevierStyleCrossRefs" href="#bib0595"><span class="elsevierStyleSup">19&#44;24</span></a> Serum electrolytes can be used to monitor fluid loss&#46; Liver and kidney function tests may be altered in erythroderma associated with severe drug reactions&#46; Specific tests to diagnose S&#233;zary syndrome include S&#233;zary cell count analysis&#46;<a class="elsevierStyleCrossRef" href="#bib0895"><span class="elsevierStyleSup">79</span></a> Possible screening tests for connective tissue diseases include antinuclear antibodies&#44; extractable nuclear antigen&#44; rheumatoid factor&#44; anti-DNA antibodies and complement levels&#46; HIV virus testing may be mandatory in high-risk populations with erythroderma&#46;<a class="elsevierStyleCrossRef" href="#bib0900"><span class="elsevierStyleSup">80</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Multiple blood cultures may be necessary to exclude Staphylococcal sepsis based on the fact that blood cultures may be contaminated secondary to cutaneous Staphylococcal colonization&#46;<a class="elsevierStyleCrossRef" href="#bib0830"><span class="elsevierStyleSup">66</span></a> When skin superinfections are suspected&#44; fungal cultures&#44; PCR for herpes simplex virus and the varicella-zoster virus can be useful&#46; Diagnosis of crusted scabies can be made by examining scrapings obtained from burrows under the microscope&#46;<a class="elsevierStyleCrossRef" href="#bib0760"><span class="elsevierStyleSup">52</span></a> Imaging studies such as a chest radiograph&#44; computed tomography&#44; and magnetic resonance may aid in the diagnosis of paraneoplastic erythroderma&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Diagnosis</span><p id="par0090" class="elsevierStylePara elsevierViewall">Being a syndromatic entity&#44; the diagnosis of erythroderma is easily made with the clinical finding of generalized erythema and desquamation involving &#8805; 90&#37; of the skin surface area&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">4</span></a> Defining the underlying disease represent a challenge for physicians and must include a profound clinicopathological correlation&#46; We describe the characteristics of the main differential diagnoses in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">General Principles of Management</span><p id="par0095" class="elsevierStylePara elsevierViewall">Exfoliative dermatitis is a dermatological emergency and severe cases require in patient care&#46;<a class="elsevierStyleCrossRefs" href="#bib0900"><span class="elsevierStyleSup">80&#44;81</span></a> The initial diagnostic approach and general principles of management for erythrodermic patients are described in detail in <a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">Treatment approach should include discontinuation of any unnecessary medications and appropriate workup to exclude an underlying malignancy&#46; Bed rest and sedation should be used when necessary&#46; Initial management of all types of erythroderma is similar&#44; even without an etiologic diagnosis&#46; Regulating environmental temperature is crucial since patients with this condition loose homeostatic body functions that prevent cooling or overheating&#46;<a class="elsevierStyleCrossRef" href="#bib0900"><span class="elsevierStyleSup">80</span></a> Skin barrier function can be improved with colloid baths and wet compresses on not more than a quarter of the body at a time&#44;<a class="elsevierStyleCrossRef" href="#bib0900"><span class="elsevierStyleSup">80</span></a> along with emollient creams and low-potency topical corticosteroids&#46;<a class="elsevierStyleCrossRef" href="#bib0910"><span class="elsevierStyleSup">82</span></a> High-potency topical corticosteroids and topical tacrolimus are not recommended since systemic absorption is enhanced by increased skin permeability&#46;<a class="elsevierStyleCrossRefs" href="#bib0915"><span class="elsevierStyleSup">83&#44;84</span></a> The initial approach to therapy must also include nutrition and fluid assessment as described in <a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Oral&#44; intramuscular or intravenous sedative antihistamines can alleviate scratching&#44; thus preventing secondary skin infections while relieving pruritus and anxiety &#40;eg&#44; hydroxyzine hydrochloride&#44; 25&#8211;50<span class="elsevierStyleHsp" style=""></span>mg P&#46;O&#46; QID&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0910"><span class="elsevierStyleSup">82</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">There is scarce high evidence-based data to determine treatment recommendations regarding erythrodermic psoriasis&#46; A panel of experts suggested cyclosporine &#40;Evidence IIB&#41; or infliximab &#40;Evidence IIB&#41; might be the most rapidly acting agents&#46; Other first-line choices are acitretin &#40;Evidence IB&#41; or methotrexate &#40;Evidence III&#41;&#44; although they usually work more slowly&#46; A second-line treatment based on case series is Etanercept &#40;Evidence IIB&#41;&#46; Use of systemic steroids is controversial as withdrawal may precipitate an erythrodermic flare&#46; Evidence for these recommendations was graded using levels of evidence developed by Shekelle et al&#46;<a class="elsevierStyleCrossRef" href="#bib0925"><span class="elsevierStyleSup">85</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">First-line treatment choices for adults with severe atopic dermatitis&#44; particularly after failure with topical treatment&#44; include narrow-band UVB phototherapy &#40;Evidence IIB&#41; or systemic immunosuppressant&#46; Oral cyclosporine has been evaluated in randomized trials and systematic reviews showing to be an adequate short-term treatment &#40;Evidence I-IIB&#41;&#46; The evidence grading scale used in these recommendations was the Strength of Recommendation Taxonomy &#40;SORT&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0930"><span class="elsevierStyleSup">86</span></a> Recent randomized clinical trials with dupilumab&#44; an interleukin &#40;IL&#41;-4 receptor alpha antagonist&#44; indicate it may be an alternative systemic therapy for long-standing severe atopic dermatitis in adults&#46;<a class="elsevierStyleCrossRef" href="#bib0935"><span class="elsevierStyleSup">87</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Treatment recommendations for pityriasis rubra pilaris are based merely on case reports and small case series&#44; to date no randomized controlled trials are available&#46; First-line therapies are oral retinoids and methotrexate&#46; Second-line therapies may include TNF-alpha inhibitors&#44; systemic steroids&#44; cyclosporine or azathioprine&#46;<a class="elsevierStyleCrossRefs" href="#bib0940"><span class="elsevierStyleSup">88&#44;89</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Patients with idiopathic erythroderma who fail to respond to topical treatments may be treated with empiric regimens such as systemic corticosteroids or other immunosuppressants such as methotrexate and cyclosporine&#59; however&#44; evidence for this approach is scarce&#46;<a class="elsevierStyleCrossRefs" href="#bib0545"><span class="elsevierStyleSup">9&#44;11&#44;22&#44;47</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Specific treatment regimens for common causes of erythroderma are described in detail in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Natural Course of Disease and Prognosis</span><p id="par0135" class="elsevierStylePara elsevierViewall">Erythroderma secondary to drug reactions improves or resolves within 2-6 weeks of drug discontinuation&#46; Exfoliative dermatitis associated with psoriasis and eczema may improve within several weeks or months&#44; yet lesions may recur after the first episode in15&#37; of patients&#46; When related to CTCL or another malignancy&#44; erythroderma may persist and be refractory&#46; Thirty percent of subjects with idiopathic erythroderma can exhibit complete remission or 50&#37; partial remission&#46;<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">13</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Prognostic studies are scarce and show conflicting results&#46; Early studies report significant mortality secondary to systemic complications&#46;<a class="elsevierStyleCrossRefs" href="#bib0665"><span class="elsevierStyleSup">33&#44;45</span></a> Low mortality has been reported in studies from recent decades&#44; probably as a result of advances in hospital care and more therapeutic options&#46;<a class="elsevierStyleCrossRefs" href="#bib0715"><span class="elsevierStyleSup">43&#44;90</span></a> However&#44; a recent retrospective population-based cohort study from Denmark found that 30&#46;8&#37; of patients with erythrodermic psoriasis and 39&#46;6&#37; with erythroderma&#44; died within the first 3 years following hospital admission&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">2</span></a> This high mortality was comparable with older studies&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusion</span><p id="par0145" class="elsevierStylePara elsevierViewall">Erythroderma is a syndromatic entity and determining its etiology may be a challenge for dermatologists&#46; Clinical features are frequently nonspecific and the dermatologist must search for cause-oriented clues&#46; Multiples biopsies along the course of the disease could potentially enhance diagnostic accuracy&#46; The initial management of erythroderma must include nutrition expert evaluation&#44; fluid imbalance assessment&#44; maintaining skin barrier function&#44; sedative antihistamines and exclusion of secondary bacterial infection&#46; This condition can be life-threatening and may require hospitalization&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of Interest</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "identificador" => "xres1102721"
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          "titulo" => "Keywords"
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          "titulo" => "Introduction"
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          "titulo" => "Epidemiology"
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          "titulo" => "Pathogenesis"
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          "identificador" => "sec0025"
          "titulo" => "Etiology"
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          "identificador" => "sec0030"
          "titulo" => "Clinical Manifestations"
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          "identificador" => "sec0035"
          "titulo" => "Systemic Manifestations"
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          "identificador" => "sec0040"
          "titulo" => "Histopathology"
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          "titulo" => "Laboratory and Imaging"
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          "titulo" => "General Principles of Management"
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    "fechaRecibido" => "2017-11-30"
    "fechaAceptado" => "2018-05-23"
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            0 => "Erythroderma"
            1 => "Exfoliative dermatitis"
            2 => "Erythema"
            3 => "Desquamation"
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          "clase" => "keyword"
          "titulo" => "Palabras clave"
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            0 => "Eritrodermia"
            1 => "Dermatitis exfoliativa"
            2 => "Eritema"
            3 => "Descamaci&#243;n"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Erythroderma is an inflammatory skin syndrome that involves desquamation and erythema of more than 90&#37; of the body surface area&#46; It represents a final clinical endpoint for many adult dermatological conditions&#46; The most frequent cause of erythroderma is psoriasis followed by eczematous conditions&#44; drug-induced reactions&#44; pityriasis rubra pilaris and cutaneous T-cell lymphomas&#46; Diagnostic approach must include a thorough history and clinical examination&#46; If the etiology of erythroderma is uncertain multiple skin biopsies may enhance diagnostic accuracy&#46; The initial management of erythroderma must include a nutrition expert evaluation&#44; fluid imbalance assessment&#44; maintaining skin barrier function&#44; sedative antihistamines and exclusion of secondary bacterial infection&#46; We present a practical review of the etiology&#44; diagnosis&#44; and treatment of this entity&#46;</p></span>"
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      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La eritrodermia es un s&#237;ndrome inflamatorio de la piel caracterizado por descamaci&#243;n y eritema en m&#225;s del 90&#37; de la superficie corporal&#46; Representa la etapa final de muchas enfermedades dermatol&#243;gicas en el adulto&#46; La causa m&#225;s frecuente es la psoriasis&#44; le siguen las enfermedades eccematosas&#44; las reacciones medicamentosas&#44; la pitiriasis rubra pilaris y los linfomas cut&#225;neos de c&#233;lulas T&#46; El abordaje diagn&#243;stico debe incluir una historia y examen f&#237;sicos exhaustivos&#46; Si se desconoce la etiolog&#237;a de la eritrodermia es posible que m&#250;ltiples biopsias a lo largo del curso de la enfermedad aumenten las posibilidades de un diagn&#243;stico correcto&#46; El abordaje inicial de la eritrodermia debe incluir la evaluaci&#243;n de un experto en nutrici&#243;n&#44; la valoraci&#243;n del balance hidroelectrol&#237;tico&#44; medidas para mantener la funci&#243;n de barrera de la piel&#44; antihistam&#237;nicos con efecto sedante y la exclusi&#243;n de infecciones bacterianas secundarias&#46; Presentamos una revisi&#243;n pr&#225;ctica de la etiolog&#237;a&#44; diagn&#243;stico y tratamiento de esta entidad&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Cuellar-Barboza A&#44; Ocampo-Candiani J&#44; Herz-Ruelas ME&#46; Eritrodermia en el adulto&#58; un enfoque pr&#225;ctico para el diagn&#243;stico y tratamiento&#46; Actas Dermosifiliogr&#46; 2018&#59;109&#58;777&#8211;790&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">&#40;A-B&#41; Erythrodermic psoriasis with generalized erythema&#44; desquamation and pustules&#46; &#40;C&#41; Histopathology reveals parakeratosis&#44; acanthosis&#44; hypogranulosis and a subcorneal pustule &#40;H&#38;E&#44; original magnification x20&#41;&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">&#40;A-B&#41; Erythrodermic atopic dermatitis with generalized erythema&#44; fine scale and increased severity in flexural creases&#46; &#40;C&#41; Histopathology reveals parakeratosis&#44; acanthosis and mild spongiosis &#40;H&#38;E&#44; original magnification x20&#41;&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Erythrodermic micosis fungoides&#46; &#40;B&#41; Histopathology reveals epidermotropism of atypical lymphocytes&#44; Pautrier&#39;s microabscesses and dermal infiltration of neoplasic cells &#40;H&#38;E&#44; original magnification x40&#41;&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Initial diagnostic approach and general principles of management for erythrodermic patients&#46;</span> BSA&#58; Body surface area&#59; BMI&#58; Body mass index&#59; CBC&#58; complete blood count&#59; ie&#58; for example&#59; PO&#58; Per os &#40;taken orally&#41;&#59; QID&#58; Quarter in die &#40;4 times a day&#41;&#59; QD&#58; Quaque die &#40;once a day&#41;&#59; BID&#58; Bis in die &#40;twice a day&#41;&#59; PET-CT&#58; positron emission tomography-computed tomography&#59; HIV&#58; Human immunodeficiency virus&#59; ANAs&#58; Antinuclear antibodies&#59; IFF&#58; Indirect immunofluorescence&#46; <span class="elsevierStyleBold">Sources and comments&#58;</span> 1&#46;- Scarisbrick et al<a class="elsevierStyleCrossRef" href="#bib0955"><span class="elsevierStyleSup">91</span></a>&#59; 2&#46;- NICE&#58; Clinical guideline for nutrition support in adults &#40;2017 uptdate&#41;<a class="elsevierStyleCrossRef" href="#bib0960"><span class="elsevierStyleSup">92</span></a>&#59; 3&#46;- Hypovolaemia criteria&#58; Sistolic blood pressure &#60; 100<span class="elsevierStyleHsp" style=""></span>mmHg&#44; Heart rate<span class="elsevierStyleHsp" style=""></span>&#62; 90 BPM&#44; Capillary refill time<span class="elsevierStyleHsp" style=""></span>&#62; 2<span class="elsevierStyleHsp" style=""></span>seconds&#44; respiratory rate<span class="elsevierStyleHsp" style=""></span>&#62; 20 breaths per minute&#44; passive leg raising suggests fluid responsiveness<a class="elsevierStyleCrossRef" href="#bib0965"><span class="elsevierStyleSup">93</span></a>&#59; 4&#46;- For further management of IV fluids&#58; NICE&#58; Clinical guideline for intravenous fluid therapy in adults in hospital &#40;2013&#41;<a class="elsevierStyleCrossRef" href="#bib0965"><span class="elsevierStyleSup">93</span></a>&#59; 5&#46;- Mart&#237;nez-Mor&#225;n et al<a class="elsevierStyleCrossRef" href="#bib0905"><span class="elsevierStyleSup">81</span></a>&#59; 6&#46;- Kanthraj et al<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">15</span></a>&#59; 7&#46;- Eichenfield et al<a class="elsevierStyleCrossRef" href="#bib0970"><span class="elsevierStyleSup">94</span></a>&#59; 8&#46;- Stevens et al&#46;<a class="elsevierStyleCrossRef" href="#bib0975"><span class="elsevierStyleSup">95</span></a></p>"
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          "leyenda" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Source&#58; Grant-Kels et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0980"><span class="elsevierStyleSup">96</span></a> Errichetti et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0985"><span class="elsevierStyleSup">97</span></a> Quay et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0990"><span class="elsevierStyleSup">98</span></a> Gupta et al&#46;<a class="elsevierStyleCrossRef" href="#bib0995"><span class="elsevierStyleSup">99</span></a></p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Etiology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Reported frequency&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Clinical clues&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Diagnostic hints&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Dermoscopy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Histopathology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Psoriasis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25 - 50&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Previous psoriatic plaques&#44; palmoplantar keratoderma&#44; nail changes&#44; arthritis&#44; scalp involvement&#44; seborrheic dermatitis-like features&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">-Most common cause<br>-Long-standing psoriasis &#40;more than 10 years from diagnosis&#41;<br>-Withdrawal of systemic or topical &#40;extensive long-term use&#41; corticosteroids&#44; methotrexate or cyclosporine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Whitish scales&#44; dotted vessels&#44; regularly arranged homogeneous reddish background&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Psoriasiform epidermal hyperplasia with confluent parakeratosis layered with neutrophils&#44; hypogranulosis&#44; and dilated tortuous papillary blood vessels&#44; Munro microabscesses&#44; spongiform pustules of Kogoj&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Spongiotic dermatitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46;12&#37; - 25&#46;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fine scales&#44; lichenification&#44; severe pruritus&#44; oozing skin&#44; erythematous papules and plaques&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Look for a history of&#58;<br>-Atopic dermatitis &#40;9&#37;&#41;<br>-Contact dermatitis &#40;6&#37;&#41;<br>-Seborrhoeic dermatitis &#40;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Atopic dermatitis&#58; yellowish scales&#47;serocrusts&#44;<br>Patchily distributed dotted vessels&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Superficial perivascular dermal infiltrate with eosinophils&#44; overlying spongiosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Drug-induced&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&#46;3 - 21&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Exfoliative scale preceded by morbilliform eruption&#44; face edema&#44; pruritus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">-Look for intake of antiepileptics&#44; allopurinol&#44; beta-lactamics&#44; sulfonamides&#44; Chinese herbs&#44; NSAIDs<br>-Commonly resolves 2-6 weeks after discontinuation of offending drug<br>-Eosinophilia<br>-Liver enzyme elevation<br>-Creatinine elevation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Perivascular infiltrate with eosinophils&#44; interface dermatitis with necrotic keratinocytes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pityriasis rubra pilaris&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;25&#37; - 8&#46;2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hyperkeratotic follicular papules&#44; islands of sparing&#44; orange-colored palmoplantarkeratoderma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">-Cephalocaudal spread<br>-Acute onset<br>-Sixth decade of life<br>-Ectroprion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Whitish scaling&#44; orange blotches&#44; scattered dotted vessels&#44; islands of non-erythematous skin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Epidermal hyperplasia with horizontal and vertical alternating orthokeratosis and parakeratosis&#44; follicular plugs with &#8220;shoulder parakeratosis&#8221;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">T-cell lymphomas &#40;S&#233;zary syndrome and Mycosis fungoides&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fissured painful palmoplantarkeratoderma&#44;<br>severe pruritus&#44; hepatosplenomegaly&#44; nail hypertrophy&#44; ectropion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">-Lymphadenopathy<br>-Alopecia<br>-Leonine facies<br>-Hepatosplenomegaly<br>-Periphereal blood&#58; sezary cells &#40;cerebriform nuclei&#41;&#44; CD4&#58;CD8 ratio of 10 or more&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mycosis fungoides&#58; serpiginous vessels with spermatozoon-like shape&#44; whitish&#8211;pinkish background&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Nuclear atypia in lymphocytes&#44; clustering of atypical cells within epidermis&#44; clonal T-cell population&#44; minimal spongiosis&#44; may show unspecific inflammatory infiltrate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab1886514.png"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Other etiologies</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dermatophytosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Look for chronic use of topical corticosteroids&#46;<br>Hyphae within stratum corneum&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Scabies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Burrows&#44; nodules on the genitalia&#44; scale in the webspaces&#44; widespread crusted plaques&#44; thick nails&#44; ketaoderma&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lichen planus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Look for pruritic&#44; violaceous papules that favor the extremities&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Immunobullous disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bilsters&#44; erosions and ulcers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dermatomyositis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Gottron papules&#44; heliotrope sign&#44; poikiloderma<br>Muscle weakness&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Paraneoplasic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Failure to thrive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Features of common causes of erythroderma in adults&#46;</p>"
        ]
      ]
      5 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">CHF&#58; congestive heart failure&#59; TB&#58; tuberculosis&#46;</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Source&#58; Patrizi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0910"><span class="elsevierStyleSup">82</span></a> and Wolverton et al&#46;<a class="elsevierStyleCrossRef" href="#bib1000"><span class="elsevierStyleSup">100</span></a></p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Etiology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Dose&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Absolute contraindications&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Important relative contraindications&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="9" align="left" valign="top">Psoriasis</td><td class="td" title="table-entry  " align="left" valign="top">Cyclosporine<br>&#40;First line&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Initial mean dose 4 mg&#47;kg&#47;day slowly reduced after remission by 0&#46;5 mg&#47;kg every 2 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Decreased renal function&#44; uncontrolled hypertension&#44; hypersensitivity&#44; active malignancy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Controlled hypertension&#44; age &#60;18 years or<span class="elsevierStyleHsp" style=""></span>&#62;64 years&#44; active infection&#44; live attenuated vaccine&#44; immunodeficiency&#44; pregnancy &#40;C&#41;&#44; concomitant immunosuppressive drug&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Infliximab<br>&#40;First line&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5 mg&#47;kg i&#46;v&#46; at week 0&#44; 2&#44; 6&#44; and later every 8 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hypersensitivity&#44; active infections&#44; concurrent use of anakinra&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Congestive heart failure&#44; family history of demyelinating diseases&#44; increased risk of malignancy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Acitretin<br>&#40;First line&#44; slow acting&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;3&#8211;0&#46;75 mg&#47;kg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pregnancy &#40;X&#41;&#44; lactation&#44; non-compliance with contraception&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Leukopenia&#44; hepatic or renal dysfunction&#44; dyslipidemia&#44; hypoithyroidism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Methotrexate<br>&#40;First line&#44; slow acting&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#46;5&#8211;15 mg&#47;week&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pregnancy &#40;X&#41; and lactation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hepatic disease&#44; decreased renal function&#44; immunodeficiency&#44; severe hematologic abnormality&#44; active infectious disease or potential reactivation of TB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Etanercept&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50<span class="elsevierStyleHsp" style=""></span>mg subcutaneous injection twice a week&#44; reduce 50 mg&#47;week after 3 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hypersensitivity&#44; active or chronic infections&#44; concurrent use of anakinra&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Congestive heart failure&#44; family history of demyelinating disease&#44; increased risk of malignancy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Phototherapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">UVB-NB&#58; Initial dosing according to skin type &#40;130-400 mJ&#47;cm2&#41; or MED &#40;50&#37; of MED&#41;&#46; Subsequent dosage increase by 15-65 mJ&#47;cm2 or &#8804;10&#37; of initial MED&#46; Treatment 3-5 times&#47;week&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pemphigus and pemphigoid&#44; lupus erythematosus with photosensitivity&#44; xeroderma pigmentosa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Photosensitivity&#47;photosensitizing medication&#44; history of skin cancer&#44; history or family history of melanoma&#44; physical impairment&#44; history of arsenic intake or ionizing radiation therapy&#44; poor compliance &#40;Menter et al&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Adalimumab&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">80<span class="elsevierStyleHsp" style=""></span>mg at week 0&#44; 40<span class="elsevierStyleHsp" style=""></span>mg at week 1&#44; later 40<span class="elsevierStyleHsp" style=""></span>mg every 2 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hypersensitivity&#44; active infections&#44; concurrent use of anakinra&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Congestive heart failure&#44; family history of demyelinating disease&#44; increased risk of malignancy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ustekinumab&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">45&#47;90<span class="elsevierStyleHsp" style=""></span>mg &#40;according to the weight&#41; at week 0&#46;4 and later every 12 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hypersensitivity&#44; active serious infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Increased risk of malignancy&#44; avoid pregnancy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Systemic corticosteroids&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Avoid&#44; as their withdrawal can result in a pustular flare or erythroderma that may be life-threatening&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="7" align="left" valign="top">Atopic dermatitis</td><td class="td" title="table-entry  " align="left" valign="top">Cyclosporin<br>&#40;FIrst line&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Initial mean dose 5 mg&#47;kg&#47;day&#44; slowly reduced after remission by 0&#46;5 mg&#47;kg every 2 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Decreased renal function&#44; uncontrolled hypertension&#44; hypersensitivity&#44; active malignancy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Controlled hypertension&#44; age &#60;18 years or<span class="elsevierStyleHsp" style=""></span>&#62;64 years&#44; active infection&#44; live attenuated vaccine&#44; immunodeficiency&#44; pregnancy &#40;C&#41;&#44; concomitant immunosuppressive drug&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Phototherapy<br>&#40;First line&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Narrowband UVB &#40;311&#8211;313 nm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pemphigus and pemphigoid&#44; lupus erythematosus with photosensitivity&#44; xeroderma pigmentosa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Photosensitivity&#47;photosensitizing medication&#44; history of skin cancer&#44; history or family history of melanoma&#44; physical impairment&#44; history of arsenic intake or ionizing radiation therapy&#44; poor compliance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Methotrexate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#8211;25 mg&#47;week slowly reduced after remission&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pregnancy &#40;X&#41; and lactation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hepatic disease&#44; decreased renal function&#44; immunodeficiency&#44; severe hematologic abnormality&#44; active infectious disease or potential reactivation of TB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mycophenolate mofetil&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#8211;2 g&#47;day slowly reduced after remission&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pregnancy &#40;D&#41;&#44; drug allergy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lactation&#44; peptic ulcer&#44; hepatic&#47;renal disease&#44; concomitant use of azathioprine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Azathioprine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">100&#8211;200 mg&#47;day slowly reduced after remission&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pregnancy &#40;D&#41;&#44; hypersensitivity&#44; active infection&#44; myelosuppression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Use of allopurinol&#44; prior use of alkylating agents&#44; hepatic disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Intravenous immunoglobulins&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 g&#47;kg&#47;month for 3&#8211;6 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Anaphylaxis secondary to previous infusions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Congestive heart failure&#44; renal failure&#44; IgA deficiency&#44; rheumatoid arthritis&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Systemic corticosteroids&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Prednisone 1 mg&#47;kg&#47;24 h&#44; then gradually decreased&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Systemic fungal infections&#44; herpes simplex keratitis&#44; hypersensitivity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hypertension&#44; CHF&#44; prior psychosis&#44; active TB&#44; positive tuberculin test&#44; osteoporosis&#44; cataracts&#44; glaucoma&#44; pregnancy &#40;C&#41;&#44; diabetes mellitus&#44; gastric disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Drug-induced</td><td class="td" title="table-entry  " align="left" valign="top">Systemic corticosteroids&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Prednisone 1 mg&#47;kg&#47;24 h&#44; then gradually decreased&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Systemic fungal infections&#44; herpes simplex keratitis&#44; hypersensitivity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hypertension&#44; CHF&#44; prior psychosis&#44; active TB&#44; positive tuberculin test&#44; osteoporosis&#44; cataracts&#44; glaucoma&#44; pregnancy &#40;C&#41;&#44; diabetes mellitus&#44; gastric disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Intravenous immunoglobulins&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High dose &#40;1 g&#47;kg&#47;day for 3 days&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Anaphylaxis secondary to previous infusions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Congestive heart failure&#44; renal failure&#44; IgA deficiency&#44; rheumatoid arthritis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Pityriasis rubra pilaris</td><td class="td" title="table-entry  " align="left" valign="top">Acitretin<br>&#40;First line&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;3&#8211;0&#46;75 mg&#47;kg&#47;day slowly reduced after remission&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pregnancy &#40;X&#41;&#44; lactation&#44; non-compliance with contraception&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Leukopenia&#44; hepatic or renal dysfunction&#44; dyslipidemia&#44; hypothyroidism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Methotrexate<br>&#40;First line&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#8211;25 mg&#47;week slowly reduced after remission&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pregnancy &#40;X&#41; and lactation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hepatic disease&#44; asses for active infectious disease or potential reactivation of TB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Systemic corticosteroids&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Prednisone 1 mg&#47;kg&#47;24 h&#44; then gradually decreased&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Systemic fungal infections&#44; herpes simplex keratitis&#44; hypersensitivity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hypertension&#44; CHF&#44; prior psychosis&#44; active TB&#44; positive tuberculin test&#44; osteoporosis&#44; cataracts&#44; glaucoma&#44; pregnancy &#40;C&#41;&#44; diabetes mellitus&#44; gastric disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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