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This chapter describes selected serious generalized skin disorders in adults and discusses their dermatologic diagnosis and treatment. Covered are erythema multiforme, toxic epidermal necrolysis, exfoliative erythroderma, the toxic infectious erythemas, disseminated viral infections, Rocky Mountain spotted fever (RMSF), disseminated gonococcal infection, meningococcemia, purpura fulminans, and pemphigus vulgaris.

The disorders erythema multiforme, toxic epidermal necrolysis, exfoliative erythroderma, staphylococcal and streptococcal toxic shock syndrome, and staphylococcal scalded skin syndrome share some features in common. Table 245-1 can help in differentiating these disorders.

Table 245-1 Comparison of Inflammatory and Infectious Generalized Skin Disorders

Erythema multiforme (EM) is an acute inflammatory skin disease presenting across a spectrum. It ranges from a localized papular eruption of the skin (EM minor) to a severe, multisystem illness (EM major; Figure 245-1) with widespread vesiculobullous lesions and erosions of the mucous membranes, known as Stevens-Johnson syndrome (Figure 245-2). The spectrum is defined by the amount of epidermal detachment present, with EM minor having no epidermal detachment, Stevens-Johnson syndrome having <10% epidermal detachment, overlapping of Stevens-Johnson syndrome and toxic epidermal necrolysis (TEN) having 10% to 30% epidermal detachment, and TEN having >30% of the body surface area with epidermal detachment.1 As the amount of epidermal detachment increases, so does the risk of death with each category. The disorder strikes all age groups, with the highest incidence in young adults (age range, 20 to 40 years), affects males twice as often as females, and occurs commonly in the spring and fall. Infection, especially with mycoplasma and herpes simplex virus (HSV); drugs, especially antibiotics and anticonvulsants; and malignancies are common precipitating factors. However, the cause is unknown in about half of cases.2

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