we report a case of a 79 year old man with erythrodermic psoriasis successfully treated during the initial response phase with the novel oral small - molecule phosphodiesterase-4 inhibitor apremilast . a 79-year - old man with hypertension and psoriasis was hospitalized for severe sepsis associated with a generalized and painful erythematous rash . he had been diagnosed with psoriasis affecting < 1% body surface area ( bsa ) three months before this presentation and was treated with topical ketoconazole and fluocinolone . two weeks before hospitalization , he received a five day oral prednisone taper prescribed by a family physician for skin rash . following this methotrexate was started for presumed psoriatic erythroderma ; however , his symptoms worsened to include progressive skin involvement , fever , and hypotension which led to hospitalization . physical exam revealed tender erythematous plaque with scale from head to toe , most prominently involving the head , neck , chest , back , upper arms , abdomen , buttocks , groin , and proximal thighs ( figure 1 ) . infectious work - up was negative ; yet fevers , leukocytosis , and cutaneous pain symptoms persisted . though bsa involvement was essentially unchanged , psoriasis plaques demonstrated reduced erythema and scaling with marked improvement in cutaneous pain symptoms ( figure 3 ) . as a result , psoriasis area and however , the patient subsequently developed new - onset atrial fibrillation attributed to apremilast which was discontinued and switched to cyclosporine . erythroderma is a rare potentially deadly exfoliative dermatitis which may result from systemic infection , drug hypersensitivity , malignancy ( e.g. cutaneous t cell lymphoma ) , and inflammatory conditions such as stevens johnson syndrome , pityriasis rubra pilaris , and erythrodermic psoriasis . initial management for severe cases includes fluid resuscitation , empiric antibiotics , and diligent diagnostic evaluation . erythrodermic psoriasis is the most common form of erythroderma and accounts for 25% of all cases . when associated with psoriasis , the erythrodermic variant represents less than 1.5% of cases and manifests with well - defined erythematous plaques and overlying silvery scale . it generally affects the entire body and may be associated with life - threatening complications such as sepsis , hypovolemic shock , and acute kidney injury secondary to cutaneous fluid loss . erythrodermic psoriasis may result from uncontrolled dermatosis , abrupt withdrawal of anti - psoriatic drugs such as steroids or methotrexate , drug reaction , systemic infection , ultraviolet burns , alcoholism , and emotional stress . skin biopsy may be helpful in diagnosis as erythroderma may develop acutely or gradually from any variant of psoriasis . treatment is largely based on aggressive supportive care and the use of anti - inflammatory immunosuppressive and biologic agents . high quality evidence - based treatment recommendations for erythordermic psoriasis are lacking due to the rarity of the condition . most randomized clinical trials on psoriasis treatments have excluded less common variants such as the erythrodermic and pustular subtypes . in light of this , first - line agents that have been used with variable efficacy include cyclosporine , infliximab , acitretin , and methotrexate . recently , biologics including ustekinumab and golimumab have also been used with reported efficacy in the treatment of erythrodermic psoriasis . systemic corticosteroids and ultraviolet light therapy are not recommended due to risks of disease exacerbation and photosensitivity . for example , we chose to treat our patient with apremilast due to the presence of pre - renal acute kidney injury which is a relative contraindication to use of the other aforementioned first - line agents . apremilast is a novel small - molecule oral medication which selectively inhibits phosphodiesterase 4 and has been shown to downregulate the production of pro - inflammatory cytokines while upregulating anti - inflammatory cytokines . the efficacy of apremilast was demonstrated in a phase iii randomized controlled trial that showed a statistically and clinically significant reduction versus placebo in the baseline psoriasis area and severity index score in patients with moderate to severe plaque psoriasis . however , a search of the published literature resulted in no reports describing the use of apremilast in erythrodermic psoriasis . our patient improved on apremilast ; however , he developed new - onset atrial fibrillation which was attributed to the medication so it was discontinued . when compared with placebo , apremilast treatment has been associated with an increased , albeit low , incidence of tachyarrhythmia , most frequently atrial fibrillation . once the patient s renal function improved , he was started on cyclosporine and his erythroderma eventually resolved . it is a rare and potentially fatal exfoliative dermatitis which needs to be recognized and treated promptly . the mainstay of treatment is founded on aggressive supportive care and use of anti - inflammatory immunosuppressive drugs , including newer biologic agents . we also observed encouraging results in treating erythrodermic psoriasis using the novel oral small - molecule phosphodiesterase-4 inhibitor apremilast . its continued use in our patient , however , was limited after the initial response period by the development of atrial fibrillation which was attributed to the medication .
erythroderma is a rare potentially deadly exfoliative dermatitis characterized by diffuse cutaneous erythema which may be associated with multi - organ dysfunction . 
 therefore , it is imperative to recognize and treat it promptly . 
 erythrodermic psoriasis is the most common form of erythroderma . 
 management of this condition is largely based on aggressive supportive care and the use of anti - inflammatory immunosuppressive and biologic agents . 
 we describe a case of psoriatic erythroderma which was triggered by withdrawal from systemic steroids and successfully treated with apremilast and cyclosporine . 
 apremilast induced atrial fibrillation limited its continued use after the initial response period .