Clinical Practice and Cases in Emergency Medicine

Introduction: Exfoliative dermatitis, also known as erythroderma, represents an infrequent clinical presentation in emergency departments (ED) and often contributes to considerable diagnostic uncertainty. The differential diagnosis is broad, and the condition may arise from a wide variety of etiologies. We report a case of severe exfoliative dermatitis characterized by gradual progression and resistance to multiple therapeutic interventions over several weeks, ultimately resulting in significant systemic complications and marked hematological abnormalities.

Case Report: A 57-year-old man presented to the ED with severe pain, pruritus, and widespread skin peeling involving more than 90% of his body surface area. The patient developed a rash following a trip to Korea about six months prior to presentation, which progressively worsened despite multiple prior diagnoses and treatments including corticosteroids, immunosuppressive therapy, and biologic agents. On presentation, the patient met systemic inflammatory response syndrome criteria and was found to have profound leukopenia, thrombocytopenia, hypoalbuminemia, and Staphylococcus aureus bacteremia. Subsequent evaluation confirmed crusted scabies complicated by secondary bacterial infection. 

Conclusion: The case demonstrates the complexity of assessing generalized rash in emergency settings and underscores the importance of a thorough history and physical, as well as maintaining a broad differential diagnosis. It shows both the physical and psychological effects of diagnostic uncertainty on treatment adherence, emphasizes early recognition, and notes systemic complications arising from multifactorial etiologies.