drug induced exfoliative dermatitis

Dermatologist and/or allergist should confirm the diagnosis, individuate the culprit agent, give indications about skin management and necessity to obtain theconsultationofthe ENT specialist, the gynecologist/urologist, the ophthalmologist and/or the pulmonologist in the case of mucosal involvement. In more severe cases continuous iv therapy can be necessary. However, according to a consensus definition [54], EMM syndrome has been separated from SJS/TEN spectrum. Drug induced exfoliative dermatitis: state of the art. Neoplastic conditions (renal and gastric carcinoma), autoimmune disease (inflammatory bowel disease), HIV infection, radiation, and food additives/chemicals have been reported to be predisposing factor [59]. Manganaro AM. Immunol Allergy Clin North Am. Rheumatology (Oxford). Hum Mol Genet. 2011;128(6):126676. On the other hand, it has been demonstrated that genetic predisposition may increase the risk for sulphonamide-induced [24] and carbamazepine-induced TEN and SJS [25]. Hematologic: anemia, including aplastic and hemolytic. It should be used only in case of a documented positivity of cultural samples. Perforin/granzyme B pathway: Nassif and colleagues have proposed a role for perforin/grazyme B in keratinocyte death [37]. Fournier S, et al. Lonjou C, et al. Kamaliah MD, et al. The SCORTEN scale is based on a minimal set of parameters as described in the following table. . Google Scholar. Unfortunately, the clinical picture does not contribute to an understanding of the underlying cause. Abstract Acute interstitial nephritis associated with hepatitis, exfoliative dermatitis, fever and eosinophilia is uncommon. All non-indispensable drugs have to be stopped because they could alter the metabolism of the culprit agent. Etoricoxib-induced toxic epidermal necrolysis: successful treatment with infliximab. Google Scholar. Erythema multiforme to amoxicillin with concurrent infection by Epstein-Barr virus. Law EH, Leung M. Corticosteroids in StevensJohnson Syndrome/toxic epidermal necrolysis: current evidence and implications for future research. Ganciclovir and cidofovir should be used when polymerase-chain reactions (PCR) on peripheral blood or other biological sample identifies a viral reactivation (HHV6, HHV7, EBV and CMV). Cutaneous graft-versus-host diseaseclinical considerations and management. Federal government websites often end in .gov or .mil. Painkiller therapy. Toxic epidermal necrolysis and StevensJohnson syndrome. Granulysin as a marker for early diagnosis of the StevensJohnson syndrome. These include a cutaneous reaction to other drugs, exacerbation of a previously existing condition, infection, metastatic tumor involvement, a paraneoplastic phenomenon, graft-versus-host disease, or a nutritional disorder. Oral hygiene with antiseptic and painkiller mouthwash (chlorhexidine+lidocaine+aluminum hydroxide) together with aerosol therapy with saline and bronchodilators can reduce upper airways symptoms. CAS Kostal M, et al. J Am Acad Dermatol. Kirchhof MG et al. Since the earliest descriptions of exfoliative dermatitis, medications have been known to be important causative agents. Rare dermatological side effects such as alopecia, exfoliative dermatitis, xeroderma, pruritus have been reported. More recently, carcinomas of the fallopian tube,12 larynx13 and esophagus14 have been reported as causes of exfoliative dermatitis. Other dermatoses associated with erythroderma are listed in Table 1.2,3,68. Erythema multiforme and toxic epidermal necrolysis. 1996;44(2):1646. d. Cysts and tumors. Hung S-I, et al. b. Atopic dermatitis. Rabelink NM, Brakman M, Maartense E, Bril H, Bakker-Wensveen CA, Bavinck JN. [81]. (See paras 3 - 42 and 3- 43.) Careers. Khalaf D, et al. It is advised against the use of silver sulfadiazine because sulphonamide can be culprit agents. Clinical clues of a drug-induced etiology include: Abrupt onset, previous morbilliform eruption, multiple, varied cutaneous morphologic lesions present together Extensive erythema is followed in 2-6 days by exfoliative scaling Pruritus can be severe, leading to scratching and lichenification in more chronic processes 2011;20(5):103441. Other patients may warrant PUVA (psoralen plus ultraviolet A) phototherapy, systemic steroids (if psoriasis has been ruled out), retinoids (for exfoliative dermatitis secondary to psoriasis and pityriasis rubra pilaris), or immunosuppressive agents such as methotrexate (Rheumatrex) and azathioprine (Imuran).2527, When used as adjunctive therapy, behavior modification designed to eliminate persistent scratching has been successful in reducing the rate of excoriation and increasing the rate of healing.28. Bourgeois GP, et al. In contrast with DRESS, eosinophilia and atypical lymphocytes are not described in patients with SJS or TEN. Erythema multiforme (EM), StevensJohnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are the main clinical presentations of drug induced ED. Article Notably, Agr inhibitors have not yet been more rigorous pre-clinical testing using the established analyzed using rigorous testing with systemic applica standards for drug development. Intravenous administration is recommended. 2002;118(4):72833. Drug induced exfoliative dermatitis (ED) are a group of rare and severe drug hypersensitivity reactions (DHR) involving skin and usually occurring from days to several weeks after drug exposure. A recently published meta-analysis by Huang [110] and coworkers on IVIG in SJS/SJS-TEN/TEN reviewed 17 studies with 221 patients and compared the results obtained with high-dosage IVIG (>2g/kg) compared to lower-dosage IVIG (<2g/kg). Chang CC, et al. Clin Exp Dermatol. The management of toxic epidermal necrolysis. Fischer M, et al. De Araujo E, et al. https://doi.org/10.1186/s12948-016-0045-0, DOI: https://doi.org/10.1186/s12948-016-0045-0. Ned Tijdschr Geneeskd. PubMedGoogle Scholar. Ethambutol Induced Exfoliative Dermatitis. In the 5 studies that concluded negatively for IVIG, the dosage was below 0.4g/kg/day and treatment was maintained for less than 5days. Abe R. Toxic epidermal necrolysis and StevensJohnson syndrome: soluble Fas ligand involvement in the pathomechanisms of these diseases. Skin and appendages: acne, bruising, erythema multiforme, exfoliative dermatitis, pruritus ani, rash, skin ulceration, Stevens . Exfoliative dermatitis is a rare inflammatory skin condition that is characterized by desquamation and erythema involving more than 90% of the body surface area. ), Phenolphthalein (Agoral, Alophen, Modane), Rifampin (Rifadin, Rimactane; also in Rifamate), Trimethoprim (Trimpex; also in Bactrim, Septra). A case of toxic epidermal necrolysis with involvement of the GI tract after systemic contrast agent application at cardiac catheterization. Gastrointest Endosc. 2012;66(3):1906. Clinical practice. Manage cookies/Do not sell my data we use in the preference centre. 1992;11(3):20710. EMs mortality rate is not well reported. Google Scholar. Google Scholar. of Internal Medicine, University of Bari, Bari, Italy, Andrea Nico,Elisabetta Di Leo,Paola Fantini&Eustachio Nettis, You can also search for this author in Joint Bone Spine. Early enteral nutrition has also a protective effect on the intestinal mucosa and decreases bacterial colonization. 2018 Jan 28;2018:9095275. doi: 10.1155/2018/9095275. Hospitalization and dermatologic consultation are indicated in most cases to ensure that all of the necessary cutaneous, laboratory and radiologic investigations and monitoring are performed. Gueudry J, et al. The EuroSCAR-study. In more severe cases antiviral therapies should be given together with intravenous immunoglobulins [93]. Correspondence to 2012;53(3):16571. Exposure to anticonvulsivants (phenytoin, phenobarbital, lamotrigine), non-nucleoside reverse transcriptase inhibitors (nevirapine), cotrimoxazole and other sulfa drugs (sulfasalazine), allopurinol and oxicam NSAIDs [2] confers a higher risk of developing SJS/TEN. Part of Article It characteristically demonstrates diffuse erythema and scaling of greater than 90% of the body surface area. 2011;38(3):23645. Loss of normal vasoconstrictive function in the dermis, decreased sensitivity to the shivering reflex and extra cooling that comes from evaporation of the fluids leaking out of the weeping skin lesions all result in thermoregulatory dysfunction that can cause hypothermia or hyperthermia.6 The basal metabolic rate also is increased in patients with exfoliative dermatitis. Ann Intern Med. J Dermatol. Summary: Drug induced interstitial nephritis, hepatitis and exfoliative dermatitis. Clinical features; Delayed type hypersensitivity; Drug hypersensitivity; Erythema multiforme; Exfoliative dermatitis; Lyells syndrome; Pathogenesis; StevensJohnson syndrome; Therapy; Toxic epidermal necrolysis. Other clinical findings include lymphadenopathy, hepatomegaly, splenomegaly, edema of the foot or ankle4,6 and gynecomastia.19, The scaling that occurs in exfoliative dermatitis can have severe metabolic consequences, depending on the intensity and the duration of the scaling. -. Linear IgA dermatosis most commonly presents in patients older than 30years. Plasmapheresis. 19 Key critical interactions are discussed below for each mpox antiviral. 2005;62(4):63842. Epilepsia. 1995;14(6):5589. 2010 Oct;35(7):723-8. doi: 10.1111/j.1365-2230.2009.03718.x. 2001;108(5):83946. Chung W-H, et al. N Engl J Med. Erythroderma is the term used to describe intense and usually widespread reddening of the skin due to inflammatory skin disease. Etanercept therapy for toxic epidermal necrolysis. The drug level peaks after 1- 4 h in plasma after ingestion with 95% protein binding. PubMed A switch to oral therapy can be performed once the mucosal conditions improve. N Engl J Med. The erythrodermic form of mycosis fungoides and the Szary syndrome may also be difficult to distinguish from benign erythroderma. Drug eruptions that initially present as morbilliform, lichenoid or urticarial rashes may progress to generalized exfoliative dermatitis. It is not completely clear whether EM and SJS are separate clinical entities or if they represent two different expressions of a single disease process. In SJS and TEN mucosal erosions on the lips, oral cavity, upper airways, conjunctiva, genital tract or ocular level are frequent [60, 6870]. In serious cases invasive ventilation can be necessary for ARDS. PTs have to be performed at least 6months after the recovery of the reaction, and show a variable sensitivity considering the implied drug, being higher for beta-lactam, glycopeptide antibiotics, carbamazepine, lamotrigine, proton pump inhibitors, tetrazepam, trimethoprimsulfametoxazole, pseudoephedrine and ramipril [7376]. Cyclosporine A (Cys A): Cys A works through the inhibition of calcineurin, that is fundamental for cytotoxic T lymphocytes activation. 2000;22(5):4137. A population-based study with particular reference to reactions caused by drugs among outpatients. Some of these patients undergo spontaneous resolution. Smith SD, et al. Tang YH, et al. Avoid rubbing and scratching. In: Eisen AZ, Wolff K, editors. Wetter DA, Camilleri MJ. In case of an oral mucositis that impairs nutrition, it is indicated to position a nasogastric tube. See permissionsforcopyrightquestions and/or permission requests. The incidence of cutaneous adverse drug reactions (CADRs) is high in HIV-infected persons; however, there are large gaps in knowledge about several aspects of HIV-associated CADRs in Africa, which carries the biggest burden of the disease. Mortality rate of patients with TEN has shown to be directly correlated to SCORTEN. doi: 10.1111/dth.15416. Drug rashes are the body's reaction to a certain medicine. 1990;126(1):437. Tohyama M, Hashimoto K. Immunological mechanisms of epidermal damage in toxic epidermal necrolysis. Stevens-Johnson syndrome and toxic epidermal necrolysis due to anticonvulsants share certain clinical and laboratory features with drug-induced hypersensitivity syndrome, despite differences in cutaneous presentations. In the hospital, special attention must be given to maintaining temperature control, replacing lost fluids and electrolytes, and preventing and treating infection. . J Eur Acad Dermatol Venereol. In: Eisen AZ, Wolff K, editors. Bethesda, MD 20894, Web Policies Med J Armed Forces India. The team should include not only physicians but also dedicated nurses, physiotherapists and psychologists and should be instituted during the first 24h after patient admission. 2012;13(1):4954. Shiga S, Cartotto R. What are the fluid requirements in toxic epidermal necrolysis? Exfoliative dermatitis is a disease process in which most, and sometimes all, of the skin is involved in erythematous inflammation resulting in massive scaling.1 A variety of diseases and other exogenous factors may cause exfoliative dermatitis. Tumor necrosis factor : TNF- seems also to play an important role in TEN [41]. This site needs JavaScript to work properly. Ann Pharmacother. 2013;69(4):37583. In: Eisen AZ, Wolff K, editors. 2012;2012:915314. This compressed maturation process results in an overall greater loss of epidermal material, which is manifested clinically as severe scaling and shedding. N Engl J Med. All the linen must be sterile. Exfoliative dermatitis, also known as erythroderma, is an uncommon but serious skin disorder that family physicians must be able to recognize and treat appropriately. [49] confirmed these results and even suggested that higher dosage regimen with 2.74g/kg seem to be more effective in survival outcome. Drug specific cytotoxic T-cells in the skin lesions of a patient with toxic epidermal necrolysis. Erythema multiforme (EM), Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are the main clinical presentations of drug induced ED. The strength of association with the development of SJS/TEN may vary among countries and historical periods, reflecting differences in ethnicities and prescription habits among the studied populations [6164]. Drug-induced hypersensitivity syndrome (DiHS) or drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a severe adverse drug-induced reaction characterized by various symptoms: skin rash, fever, lymph node enlargement and internal organ involvement, which starts within 2 weeks to 3 months after drug initiation. Clin Pharmacol Ther. PubMed National Library of Medicine Mayo Clin Proc. Erythema multiforme. Common acute symptoms include abdominal pain or cramps, nausea, vomiting, and diarrhea, jaundice, skin rash and eyes dryness and therefore could mimic the prodromal and early phase of ED. Its also characterized by a cell-poor infiltrate, where macrophages and dendrocytes with a strong TNF- immunoreactivity predominate [6, 50]. Unable to load your collection due to an error, Unable to load your delegates due to an error, Erythema multiforme (photo reproduced with permission of Gary White, MD): typical target lesions (, Mortality rate of patients with TEN has shown to be directly correlated to SCORTEN. Disasters. The most common causes of exfoliative dermatitis are best remembered by the mnemonic device ID-SCALP. J Am Acad Dermatol. Fitzpatricks dermatology in general medicine. official website and that any information you provide is encrypted Drug reactions are one of the most common causes of exfoliative dermatitis. [113] retrospectively compared mortality in 64 patients with ED treated either with iv or oral Cys A (35mg/kg) or IVIG (25g/Kg). Moreover, after granulysin depletion, they observed an increase in cell viability. Albumin is recommended only is albumin serum level is <2.5mg/dL. Beneficial effect of plasma exchange in the treatment of toxic epidermal necrolysis: a series of four cases. Pehr K. The EuroSCAR study: cannot agree with the conclusions. Malignancies are a major cause of exfoliative dermatitis. In fact, it was demonstrated that the specificity of the TCR is a required condition for the self-reaction to occur. Sassolas B, et al. Clinical, etiologic, and histopathologic features of StevensJohnson syndrome during an 8-year period at Mayo Clinic. J Popul Ther Clin Pharmacol. Antitumour necrosis factor-alpha antibodies (infliximab) in the treatment of a patient with toxic epidermal necrolysis. Br J Dermatol. Nutritional support. J Invest Dermatol. The timing of the rash can also vary. Article Studies indicate that mycosis fungoides may cause 25 to 40 percent of all cases of malignancy-related erythroderma.6,7 The erythroderma may arise as a progression from a previous cutaneous T-cell lymphoma lesion or appear simultaneously with the cutaneous T-cell lymphoma, or it may precede the appearance of the cutaneous T-cell lymphoma lesion. . . Kirchhof MG, et al. J Am Acad Dermatol. Because a certain degree of cross-reactivity between the various aromatic anti-epileptic drugs exists, some HLAs have been found to be related to SJS/TEN with two drugs, as the case of HLA-B*1502 with both phenytoin and oxcarbazepine [32]. 583-587. Gastrointestinal: pancreatitis, glossitis, dyspepsia. Am J Dermatopathol. Tohyama M, et al. sharing sensitive information, make sure youre on a federal Infectious agents are the major cause of EM, in around 90% of cases, especially for EM minor and in children. Nassif A, et al. Bullous dermatoses can be debilitating and possibly fatal. Therefore, it is important to identify and treat any underlying disease whenever possible and to remove any contributing external factors.2, Most published studies of exfoliative dermatitis have been retrospective and thus do not address the issue of overall incidence. EM is a self-limited skin condition mainly associated with infections and drugs [53, 54]. Drug induced exfoliative dermatitis (ED) are a group of rare and severe drug hypersensitivity reactions (DHR) involving skin and usually occurring from days to several weeks after drug exposure. 2007;48(5):10158. Erythema multiforme (EM), Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are the main clinical presentations of drug induced ED. Mucosal involvement could achieve almost 65% of patients [17]. Exfoliative dermatitis is a rare inflammatory skin condition that is characterized by desquamation and erythema involving more than 90% of the body surface area. 1993;129(1):926. The dermis shows an inflammatory infiltrate characterized by a high-density lichenoid infiltrate rich in T cells (CD4+ more than CD8+) with macrophages, few neutrophils and occasional eosinophils; the latter especially seen in cases of DHR [5, 50]. 2008;128(1):3544. EMM is a clinically severe, potentially life-threatening, extensive sloughing of epidermis, generally involving mucosal tissue. Association of HLA-B*1502 allele with carbamazepine-induced toxic epidermal necrolysis and StevensJohnson syndrome in the multi-ethnic Malaysian population. 2009;182(12):80719. As written before, Sassolas B. et al. A serious cutaneous adverse drug reaction namely exfoliative dermatitis (erythroderma) is associated with isoniazid use . Each of these physiologic disruptions is potentially life-threatening. Fernando SL. Applications of Immunopharmacogenomics: Predicting, Preventing, and Understanding Immune-Mediated Adverse Drug Reactions. Rzany B, et al. Among the anti-tubercular drugs exfoliative dermatitis is reported with rifampicin, isoniazid, ethambutol, pyrazinamide, streptomycin, PAS either singly or in combination of two drugs in some cases. Curr Allergy Asthma Rep. 2014;14(6):442. Guidelines for the management of drug-induced liver injury[J]. Int J Dermatol. Epub 2022 Mar 9. Szary syndrome, the leukemic variant of mycosis fungoides, is also associated with exfoliative dermatitis. ALDEN, an algorithm for assessment of drug causality in StevensJohnson Syndrome and toxic epidermal necrolysis: comparison with case-control analysis. 2015;21:13343. Barbaud A, et al. The clinical course of patients with malignancies depends on the type of malignancy and the response to appropriate therapy. Chung WH, Hung SI. Overall, T cells are the central player of these immune-mediated drug reactions. 2008;53(1):28. If cutaneous pathology also mimics cutaneous T-cell lymphoma, it can be very difficult to differentiate a drug-induced skin condition from exfoliative dermatitis associated with a malignancy.2,9. J Dermatol Sci. Bookshelf 2008;34(1):636. An increased metabolism is typical of patients with extended disepithelizated areas. Morel E, et al. Before 2007;62(12):143944. 2011;364(12):113443. Moreover, the time necessary for cells to mature and travel through the epidermis is decreased. Exfoliative dermatitis, including Stevens-Johnson syndrome, drug rash with eosinophilia and systemic symptoms, and toxic epidermal necrolysis, has occurred with anti-PD-1/PD-L1 treatments. J Am Acad Dermatol. Gonzalez-Delgado P, et al. Herpes simplex virus (HSV) 1 and 2 are the main triggers in young adults (>80% of cases), followed by Epstein-Barr virus (EBV), and Mycoplasma pneumonia [5558]. Skin manifestations of drug allergy. The time interval between the appearance of exfoliative dermatitis and the appearance of cutaneous T-cell lymphoma lesions can vary from months to years or even decades. Download Free PDF. Effects of treatments on the mortality of StevensJohnson syndrome and toxic epidermal necrolysis: a retrospective study on patients included in the prospective EuroSCAR Study. Arch Dermatol. J Pharm Health Care Sci. Generalized. Paquet P, et al. In the acute phase, before determination of the etiology, treatment consists of measures to soothe the inflamed skin. 2013;69(2):1734. 2010;88(1):608. Mild to severe alopecia and transient or permanent nail dystrophy also may be encountered. PubMed Skin testing in delayed reactions to drugs. Case Presentation: We report the development of forearm panniculitis in two women during the treatment with Panitumumab (6 mg/Kg intravenous every 2 weeks) + FOLFOX-6 (leucovorin, 5- fluorouracil, and oxaliplatin at higher dosage) for the . Increased level of retinoid acid could be responsible for keratinocytes apoptosis [99]. Pharmacogenomics J. Skin conditions. Options include use of PUVA light therapy, total-body electron beam irradiation, topical nitrogen mustard, systemic chemotherapy and extracorporeal photopheresis. During the acute reaction, diagnosis of ED is mainly based on clinical parameters. . Incidence and drug etiology in France, 1981-1985. These molecules may play a role in amplifying the immune response and in increasing the release of other toxic metabolites from inflammatory cells [48]. CAS Letko E, Papaliodis DN, Papaliodis GN, Daoud YJ, Ahmed AR, Foster CS. tion in models of the types of systemic disease for S. aureus pathogenesis research is also expected to receive which anti-virulence drugs would be most desirable. 2013;133(5):1197204. 2011;71(5):67283. Narita YM, et al. 1991;97(4):697700. Grosber M, et al. TEN is also known as Lyell syndrome, since it was first described by Alan Lyell in 1956 [2, 60]. Growth-factors (G-CSF). J Allergy Clin Immunol. Toxic epidermal necrolysis and StevensJohnson syndrome. J Dtsch Dermatol Ges. Two Cases in Adult Patients. Albeit the lack of epidemiologic data regarding EM, its reported prevalence is less than 1% [710]. J Allergy Clin Immunol. . Combination of infliximab and high-dose intravenous immunoglobulin for toxic epidermal necrolysis: successful treatment of an elderly patient. Interferon alfa (Roferon-A, Intron A, Alferon N), Isoniazid (Laniazid, Nydrazid; also in Rifamate, Rimactane), Isosorbide dinitrate (Isordil, Sorbitrate), Para-amino salicylic acid (Sodium P.A.S. These patches tend to spread until, after a matter of days or weeks, most of the skin surface is covered with an erythematous, pruritic eruption. Br J Dermatol. Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS): Focus on the Pathophysiological and Diagnostic Role of Viruses. 1994;331(19):127285. Shared and restricted T-cell receptor use is crucial for carbamazepine-induced Stevens-Johnson syndrome. Robyn A. McMenamin, L M. Davies and P. W. Craswell, Aust. SCORTEN: a severity-of-illness score for toxic epidermal necrolysis. Kreft B, et al. Springer Nature. The type of rash that happens depends on the medicine causing it and your response. and transmitted securely. Lerch M, Mainetti C, Terziroli Beretta-Piccoli B, Harr T. Clin Rev Allergy Immunol. (2.4, 5.6) Embryo-fetal Toxicity: Can cause fetal harm. What are Drug Rashes? Synthetic bilaminar membranes with silver nitrate have also a role in skin repairing and avoid protein loss through the damaged skin [100, 101]. J Am Acad Dermatol. A pseudolymphoma reaction with fever, arthralgias, lymphadenopathy, hepatosplenomegaly, anemia and erythroderma may develop as a result of hypersensitivity to dapsone or antiepileptic drugs. Ko TM, et al. The most commonly used steroids were methylprednisolone, prednisolone and dexamethasone. Also, physicians should be vigilant about possible secondary infection, whether cutaneous, pulmonary or systemic. Antipyretic therapy. J Invest Dermatol. Nature. These measures include bed rest, lukewarm soaks or baths, bland emollients and oral antihistamines.2527, In patients with chronic idiopathic erythroderma, emollients and topical steroids may be effective. It was used with success in different case reports [114116]. Liver injury and exfoliative dermatitis caused by nifuratel[J]. In spared areas it is necessary to avoid skin detachment. The most important actions to do are listed in Fig. For these reasons, patients should be admitted to intensive burn care units or in semi-intensive care units where they may have access to sterile rooms and to dedicated medical personnel [49, 88]. Wetter DA, Davis MD. Exanthematous drug eruptions. Volume 8, Issue 1 Pages 1-90 (August 1994). Clin Exp Allergy. A multidisciplinary team is fundamental in the therapeutic management of patients affected by exfoliative DHR. oboda J, Dudzik A, Chomyszyn-Gajewska M. Ramirez GA, Ripa M, Burastero S, Benanti G, Bagnasco D, Nannipieri S, Monardo R, Ponta G, Asperti C, Cilona MB, Castagna A, Dagna L, Yacoub MR. Microorganisms. Li X, et al. MalaCards based summary: Exfoliative Dermatitis is related to holocarboxylase synthetase deficiency and dermatitis, and has symptoms including exanthema An important gene associated with Exfoliative Dermatitis is SPINK5 (Serine Peptidase Inhibitor Kazal Type 5).

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