Erythema [Erythroderma]
Erythema [Erythroderma]: Excerpt from Nursing: Interpreting Signs and Symptoms
Dilated or congested blood vessels produce red skin, or erythema, the most common sign of skin inflammation or irritation. Erythema may be localized or generalized and may occur suddenly or gradually. Skin color can range from bright red in patients with acute conditions to pale violet or brown in those with chronic problems. Erythema must be differentiated from purpura, which causes redness from bleeding into the skin. When pressure is applied directly to the skin, erythema blanches momentarily, but purpura doesn't.
Erythema usually results from changes in the arteries, veins, and small vessels that lead to increased small-vessel perfusion. Drugs and neurogenic mechanisms can allow extra blood to enter the small vessels. Erythema can also result from trauma and tissue damage; changes in supporting tissues, which increase vessel visibility; and many rare disorders.
Action stat!
If the patient has sudden progressive erythema with a rapid pulse, dyspnea, hoarseness, and agitation, quickly take his vital signs. These may be indications of anaphylactic shock. Provide emergency respiratory support and give epinephrine.
History and physical examination
If erythema isn't associated with anaphylaxis, obtain a detailed health history. Find out how long the patient has had the erythema and where it first began. Has he had associated pain or itching? Has he recently had a fever, upper respiratory tract infection, or joint pain? Does he have a history of skin disease or other illness? Does he or anyone in his family have allergies, asthma, or eczema? Find out if he has been exposed to someone who has had a similar rash or who's now ill. Did he have a recent fall or injury in the area of erythema?
Obtain a complete drug history, including recent immunizations. Ask about food intake and exposure to chemicals.
Begin the physical examination by assessing the extent, distribution, and intensity of erythema. Look for edema and other skin lesions, such as hives, scales, papules, and purpura. Examine the affected area for warmth, and gently palpate it to check for tenderness or crepitus.
Medical causes
Allergic reaction.Foods, drugs, chemicals, and other allergens can cause an allergic reaction and erythema. A localized allergic reaction also produces hivelike eruptions and edema.
Anaphylaxis, a life-threatening condition, produces relatively sudden erythema in the form of urticaria. It also produces flushing; facial edema; diaphoresis; weakness; sneezing; bronchospasm with dyspnea and tachypnea; shock with hypotension and cool, clammy skin; and, possibly, airway edema with hoarseness and stridor.
Burns.With thermal burns, erythema and swelling appear first, possibly followed by deep or superficial blisters and other signs of damage that vary with the burn's severity. Burns from ultraviolet rays, such as sunburn, cause delayed erythema and tenderness on exposed areas of the skin.
Candidiasis.When candidiasis—a fungal infection—affects the skin, it produces erythema and a scaly, papular rash under the breasts and at the axillae, neck, umbilicus, and groin, also known as intertrigo. Small pustules commonly occur at the periphery of the rash (satellite pustulosis).
Cellulitis.Erythema, tenderness, and edema are a result of a bacterial infection of the skin and subcutaneous tissue.
Dermatitis.Erythema commonly occurs in this family of inflammatory disorders. With atopic dermatitis, erythema and intense pruritus precede the development of small papules that may redden, weep, scale, and lichenify. These occur most commonly at skin folds of the extremities, neck, and eyelids.
Contact dermatitis occurs after exposure to an irritant. It quickly produces erythema and vesicles, blisters, or ulcerations on exposed skin.
With seborrheic dermatitis, erythema appears with dull red or yellow lesions. Sharply marginated, these lesions are sometimes ring shaped and covered with greasy scales. They usually occur on the scalp, eyebrows, ears, and nasolabial folds, but they may form a butterfly rash on the face or move to the chest or to skin folds on the trunk. This disorder is common in patients infected with human immunodeficiency virus and in infants (cradle cap).
Dermatomyositis.Dermatomyositis produces a dusky lilac rash on the face, neck, upper torso, and nail beds. Gottron's papules (violet, flat-topped lesions) may appear on finger joints.
Erythema annulare centrifugum.Small, pink infiltrated papules appear on the trunk, buttocks, and inner thighs, slowly spreading at the margins and clearing in the center. Itching, scaling, and tissue hardening may occur.
Erythema marginatum rheumaticum.Associated with rheumatic fever, erythema marginatum rheumaticum causes erythematous lesions that are superficial, flat, and slightly hardened. They shift, spread rapidly, and may last for hours or days, recurring after a time.
Erythema multiforme.Erythema multiforme minor has typical urticarial red-pink iris-shaped localized lesions with little or no mucous membrane involvement. Most lesions occur on flexor surfaces of the extremities. Burning or itching may occur before or in conjunction with lesion development. Lesions appear in crops and last 2 or 3 weeks. After 1 week, individual lesions become flat or hyperpigmented. Early signs and symptoms may include a mild fever, cough, and sore throat.
Erythema multiforme major usually occurs as a drug reaction; has widespread symmetrical, bullous lesions that may become confluent; and includes erosions of the mucous membranes. Erythema is characteristically preceded by blisters on the lips, tongue, and buccal mucosa and a sore throat. Additional signs and symptoms that manifest early in the course of the disease include a cough, vomiting, diarrhea, coryza, and epistaxis. Later signs and symptoms include a fever, prostration, difficulty with oral intake due to mouth and lip lesions, conjunctivitis due to ulceration, vulvitis, and balanitis. The maximal variant of this disease is considered by many to be Stevens-Johnson syndrome, a multisystem disorder that can occasionally be fatal. In addition to all signs and symptoms mentioned above, the patient develops exfoliation of the skin from disruptions of bullae, although less than 10% of the body surface area is affected. These areas resemble second-degree thermal burns and should be cared for as such. Fever may rise to 102° F to 104° F (38.9° C to 40° C). The patient may also experience tachypnea; a weak, rapid pulse; chest pain; malaise; and muscle or joint pain.
Erythema nodosum.Sudden bilateral eruption of tender erythematous nodules characterizes erythema nodosum. These firm, round, protruding lesions usually appear in crops on the shins, knees, and ankles, but may occur on the buttocks, arms, calves, and trunk as well. Other effects include a mild fever, chills, malaise, muscle and joint pain and, possibly, swollen feet and ankles. Erythema nodosum is associated with various diseases, most notably inflammatory bowel disease, sarcoidosis, tuberculosis, and streptococcal and fungal infections.
Gout.Gout is characterized by tight and erythematous skin over an inflamed, edematous joint.
Kawasaki syndrome.This acute illness of unknown cause commonly produces a rash or erythema. No test is available for Kawasaki syndrome, which can cause serious heart damage and death if not detected and treated immediately. Additional characteristic signs include fever, conjunctival injection, and lymphadenopathy.
Lupus erythematosus.Discoid and systemic lupus erythematosus (SLE) can produce a characteristic butterfly rash. This erythematous eruption may range from a blush with swelling to a scaly, sharply demarcated, macular rash with plaques that may spread to the forehead, chin, ears, chest, and other sun-exposed parts of the body.
With discoid lupus erythematosus,telangiectasia, hyperpigmentation, ear and nose deformity, and mouth, tongue, and eyelid lesions may occur.
With SLE, an acute onset of erythema may also be accompanied by photosensitivity and mucous membrane ulcers, especially in the nose and mouth. Mottled erythema may occur on the hands, with edema around the nails and macular reddish purple lesions on the fingers. Telangiectasia occurs at the base of the nails or eyelids, along with purpura, petechiae, ecchymoses, and urticaria. Joint pain and stiffness are common. Other findings vary according to the body systems affected, but typically include a low-grade fever, malaise, weakness, a headache, arthralgia, arthritis, depression, lymphadenopathy, fatigue, weight loss, anorexia, nausea, vomiting, diarrhea, and constipation.
Psoriasis.Silvery white scales over a thickened erythematous base usually affect the elbows, knees, chest, scalp, and intergluteal folds. The fingernails may become thick and pitted.
Raynaud's disease.Typically, the skin on the hands and feet blanches and cools after exposure to cold and stress. Later, it becomes warm and purplish red.
Rosacea.Scattered erythema initially develops across the center of the face, followed by superficial telangiectases, papules, pustules, and nodules. Rhinophyma may occur on the lower half of the nose.
Rubella.Typically, flat solitary lesions join to form a blotchy pink erythematous rash that spreads rapidly to the trunk and extremities in this disorder. Occasionally, small red lesions (Forschheimer spots) occur on the soft palate. Lesions clear in 4 or 5 days. The rash usually follows a fever (up to 102° F [38.9° C]), a headache, malaise, a sore throat, a gritty eye sensation, lymphadenopathy, pain in the joints, and coryza.
Other causes
Drugs.Many drugs commonly cause erythema. (See Drugs associated with erythema, page 242.)
Radiation and other treatments.Radiation therapy may produce dull erythema and edema within 24 hours. As the erythema fades, the skin becomes light brown and mildly scaly. Any treatment that causes an allergic reaction can also cause erythema.
Nursing considerations
▪ Monitor and replace fluids and electrolytes, especially in patients with burns or widespread erythema.
▪ Withhold all medications until the cause of the erythema has been identified.
▪ Administer an antibiotic and a topical or systemic corticosteroid as ordered.
▪ For the patient with itching skin, give soothing baths or apply open wet dressings containing starch, bran, or sodium bicarbonate.
▪ Administer an antihistamine and analgesic as needed.
▪ For a burn patient with erythema, immerse the affected area in cold water, or apply a sheet soaked in cold water to reduce pain, edema, and erythema.
▪ Prepare the patient for diagnostic tests, such as skin biopsy to detect cancerous lesions, cultures to identify infectious organisms, and sensitivity studies to confirm allergies.
▪ Have the patient with leg erythema keep his legs elevated above heart level.
Patient teaching
▪ Stress the avoidance of sun exposure and use of sunblock.
▪ Teach the patient methods to relieve itching.
▪ Explain the underlying cause of the patient's erythema and its treatment.
Pictures
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Book Source Details
- Book Title: Nursing: Interpreting Signs and Symptoms
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Nursing: Interpreting Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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