The erythematous rash and fine scaling on our patient involved more than 90% of the body surface area and this was clinically consistent with the diagnosis of exfoliative dermatitis7
. Exfoliative dermatitis may be caused by a variety of underlying dermatoses, drug reactions and malignancies such as lymphoma, leukemia and solid tumors7-9
Acute cutaneous GVHD usually presents as a pruritic or burning erythematous eruption of the palms, soles, neck and trunk. More severe reactions may progress to exfoliative dermatitis or total epidermal sloughing that resembles toxic epidermal necrolysis2
. Chronic cutaneous GVHD has traditionally been classified into the lichenoid and scleroderma-like forms3
. However, the initial presentation is sometimes subtle and a variety of less common cutaneous manifestations may be prevalent such as marked xerosis, ichthyosis, morbilliform rash, psoriasiform plaques and exfoliative dermatitis10
Creamer et al.6
anecdotally reported on cases of chronic cutaneous GVHD with the clinical features of exfoliative dermatitis. In their study, out of 254 patients who had undergone allogenic hematopoietic stem cell transplantations (HSCT), 10 patients developed exfoliative dermatitis. The histopathologic examination revealed the combined features of both eczema, as indicated by epidermal spongiosis, and GVHD, as indicated by satellite cell necrosis. Creamer et al.6
named this cutaneous manifestation as an eczematoid GVHD. In addition, Hymes et al.10
also suggested that exfoliative dermatitis is a clinical variant of chronic cutaneous GVHD. On the other hand, Cook-Norris and Weenig11
commented on the article of Creamer et al. that the eczematoid presentation may be more accurately classified as a variant of acute GVHD.
When acute cutaneous GVHD is progressing unfavorably, it can present as an exfoliative dermatitis or widespread epidermal necrolysis2
. Hence, the possibility of late onset acute GVHD12
, which develops during the period of chronic GVHD, must be considered in our case. However, our patient had classic exanthematous acute GVHD earlier, and this resolved completely after a short course of prednisone. On the day 115 after transplantation, she developed a measle-like papulosquamous rash that was different from the previous skin lesions and it was not easily controlled with administering systemic immunosuppressive therapy. The oral mucositis and the high levels of liver enzymes in our case may be suggestive of acute GVHD, but chronic GVHD is also accompanied by oral involvement in 90% of the cases and by extracutaneous involvement such as liver disease13
. Moreover, histopathological examination showed hypergranulosis, acanthosis and mild spongiosis, which excluded the possible diagnosis of acute cutaneous GVHD. Therefore, we suggest that in our patient, the exfoliative dermatitis that was observed both clinically and histopathologically was expressed as a manifestation of chronic GVHD.