During his hospital stay, the patient is seen by the infectious disease and nephrology services. The patient initially responds favorably to therapy, but subsequently develops worsening renal insufficiency, and the cyclosporine is discontinued in favor of adalimumab. The patient is started on intravenous antibiotics because some of the involved areas of skin appeared cellulitic.

On day four in the hospital, the patient is transferred to another facility to continue therapy under the direct care of his dermatologist. The anasarca has lessened, and his lactic acidosis and acute kidney injury have resolved. Blood cultures are negative, and the generalized fiery red rash has significantly improved.

There is disagreement on the epidemiology of psoriasis, but a recent meta-analysis concluded that the adult prevalence in the United States ranges from 2.2 percent to 3.15 percent.⁴ Erythrodermic psoriasis is estimated to affect between 1 percent and 2.25 percent of those who have psoriasis.5 While erythrodermic psoriasis can be associated with a high risk of deterioration and mortality due to secondary infection and sepsis, there are no data on mortality rates, due to the overall low incidence of erythrodermic psoriasis flares.⁵

Mr. Brock is a medical student at the University of Arizona College of Medicine in Tucson.

Dr. Hannafin is in the department of emergency medicine at Chandler Regional Medical Center in Chandler, Arizona.

Dr. LoVecchio is vice chair and research director at the Maricopa Medical Center in Phoenix and professor of emergency medicine, pharmacology, and medicine at the University of Arizona College of Medicine.

References

1. Boyd AS. Menter A. Erythrodermic psoriasis: precipitating factors, course, and prognosis in 50 patients. J Am Acam Dermatol. 1989;21:985-91.
2. Rosenbach M, Hsu S. Treatment of erythrodermic psoriasis: from the Medical Board of the National Psoriasis Foundation. J Am Acam Dermatol. 2010;62.4655-62.
3. Green MS, Prystowsky JH. Infectious complications of erythrodermic psoriasis. J Am Acam Dermatol. 1996;5:911-14.
4. Parisi R, Symmons DP, Griffiths EC. Global epidemiology of psoriasis: a systematic review of incidence and prevalence. J Invest Dermatol. 2013;133:377-85.
5. Koo JY, Levin EC, Leon A, et al. Moderate to Severe Psoriasis, Fourth Edition. CRC Press. 2014;17:277-286.