| Background and Objectives:Erythrodermic psoriasis(EP)is a rare form of severe psoriasis,which is a critical condition and difficult to treat.However,studies concerning etiology,clinical characteristics,and prognosis of EP are rare,especially long-term follow-up studies and large sample studies.The objectives of this study were to summerize the clinial features of EP Patients,to propose a practical and accurate method for assessing the severity of EP,to identify the risk factors of EP,and to analyse the response rate of different drugs and prognostic factors of EP.Methods:It was a retrospective case-control study based on inpatient psoriasis patients.The case group consisted of 143 EP patients who were hospitalized in our dermatology department during January 2005 to October 2015.The control group was chosen from moderate-to-severe plaque psoriasis patiests,who were hospitalized during the same period.Patients from the control group were 1:1 matched in terms of sex and age to patients from the case group.Then we established a method to evaluate the severity of EP.If a patient showed at least two of the following three characteristics,he or she can be defined as a moderate-to-severe EP patient.If a patient showed less than two characteristics mild EP,he or she can be defined as a mild EP patient.The three characteristics are 1)body temperature greater than 37.3 degrees Celsius during the course,2)swelling and exudation of more than half of the skin lesion and 3)superficial lymphadenopathy.Finally,prognostic factors and the hazard ratio of prognosis were obtained by studying clinical features and follow-up information.The endpoint of the observation was death or the end of the study.Data was processed and analyzed using SPSS version 2.0.Risk factors of the disease were obtained by matched logistic regression.Disease-free survival curve was plotted using Kaplan-Meier estimator,and the prognosis was investigated by Cox regression analysis.Results:1.Patients with EP were more likely to present swelling and exudation of skin lesions,palmoplantar keratoderma,conjunctivitis,fever,chills,lower extremity edema,superficial lymphadenopathy,fatigue,sleep disorders(p<0.001)and weight loss(p=0.002).But there was no difference in itching,scalp and nail involvement(p>0.05)between the case group and the control group.2.Laboratory findings of EP patients showed elevating WBC count,NEU ratio and EOS ratio;increasing hsCRP,accelerating ESR,high LDH level,low urea level,hypocalcemia,hypoproteinemia;low serum LDL and HDL level compared to patients with plaque psoriasis(p<0.01).Also,electrocardiogram abnormalities,anemia,and infection were significantly more common in EP patients(p<0.01).3.The onset age of psoriasis,the course of psoriasis,individual history,family history did not differ from those of plaque psoriasis patients(p>0.05).The proportion of psoriatic arthritis is larger in EP patients(p=0.007).EP patients were more often hospitalized(p=0.001),had more former usage of immunosuppressants(p<0.001)and systemic corticosteroids(p<0.001)than patients with plaque psoriasis.But there was no significant difference in the previous use of acitretin,biological agents,traditional Chinese medicine and phototherapy between the two groups(p>0.05).4.101(69.9%)EP patients were converted from plaque psoriasis,35(24.5%)EP patients were from pustular psoriasis,and 7(5.6%)EP patients had initial onset of EP.22(15.4%)EP patients were accompanied with psoriatic arthritis.5.Inducement of EP included withdrawl of systemic treatment(33.6%),infection(26.8%),drugs(17.5%),skin irritation(11.9%),food(11.9%),psychological factors(10.5%),hair dye and perm(2.1%),and pregnancy(1.4%).There were 14%of patients developed EP without obvious causes.6.Systemic treatment of EP was primaryly based on acitretin,combining with immunosuppressants,biological agents,and corticosteroids.Total response rate of systemic treatment in this study was 88.4%.Acitretin was effective for recurrent patients.The 5-year erythroderma-free survival rate was 86.9%and 10-years erythroderma-free survival rate was 82.2%.7.According to our method for assessing the severity of EP,62(43.4%)patients belonged to mild EP group,and the remaining 74(56.6%)patients were defined as moderate-to-severe EP.More moderate-to-severe EP were developed from pustular psoriasis(p=0.028).Moderate-to-severe EP patients showed remarkably increased inflammatory markers(p<0.01),the tendency of suffering anemia(p<0.001)and hypoalbuminemia(p<0.001),and longer average hospital stays(p=0.013).More patients were using immunosuppressants and combined therapy in moderate-to-severe EP group during the hospital stays(p=0.001).8.The risk factors of EP were alcohol(OR=6.321,95%CI 1.115-35.822),history of systemic corticosteroids usage(OR=5.689,95%CI 2.205-14.677)and history of immunosuppressants usage(OR=7.716,95%CI 1.591-13.981).9.Pruritus(HR=3.127,95%CI,1.217-8.039)and lymph node enlargement(HR=2.290,95%CI,1.098-4.773)were risk factors for relapse and poor prognosis for patients with EP.The long duration of psoriasis before the onset of EP was a protective factor for prognosis(HR=0.938,95%CI,0.898-0.980).Conclusions:1.EP patients often presented with more severe skin and mucous involvement,general symptoms and poorer general status.Patients with EP often showed elevated inflammatory markers,decreased nutritional indicators.Meanwhile,the number of patients accompanied with electrocardiogram abnormalities,anemia and infection was significantly greater than that of plaque psoriasis patients.EP patients were more likely to have psoriatic arthritis,more frequently hospitalized with psoriasis,treated with immunosuppressants and systemic corticosteroids before.2.Our method for estimating the severity of EP was accorded to body temperature,swelling and exudation of skin lesions,and superficial lymphadenopathy.Using theproposed method we divided the EP patiemts into two groups:mild and moderate-to-severe EP patients.This method was practical and reasonable,therefore it might play an important role in cinical work.3.The risk factors of developing EP included alcohol,previous use of systemic corticosteroids and immunosuppressants.4.About 20%of the patients suffered from recurrence or death due to EP in the following 10 years after discharge from the hospital.Acitretin was effective to recurrent cases.Thus we suggested that patients with EP should be closely followed up,and recurrent patients should be actively treated.5.Pruritus and lymphadenopathy were risk factors for relapse and poor prognosis for EP patients.Also,the long duration of psoriasis before the onset of EP indicated smaller risk of recurrence. |
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