Erythema multiforme: Difference between revisions
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==Disposition== | ==Disposition== | ||
*For mild cases, treat as above with dermatology follow-up | |||
*For severe cases with multiple lesions / severe mucous membrane or tracheobronchial involvement with impaired PO intake, dehydration, or secondary infection: inpatient admission | |||
**May require specialized ICU or burn unit care | |||
==See Also== | ==See Also== |
Revision as of 02:31, 31 October 2014
Background
- Erythema Multiforme (EM) is an acute, self-limited skin condition precipitated by a variety of factors:
- Infections:
- Viral: HSV, hepatitis, influenza A
- Fungal: dermatophytosis, histoplasmosis, coccidioidomycosis
- Bacterial: streptococcus, tuberculosis
- Drugs:
- Antibiotics (penicillin, sulfonamides), anticonvulsants (phenytoin, barbiturates), NSAIDS, aspirin, antituberculous meds, allopurinol, etc.
- Collagen Vascular Disorders:
- RA, SLE, dermatomyositis, polyarteritis nodosa
- Others:
- Pregnancy, cold weather, sunlight, contact exposure, foods, malignancy, hormonal
- Infections:
- Peak incidence in second and third decades of life
- Despite multiple associations, thought to be triggered by HSV in most cases
- Usually self-limited and resolves within 2-6 weeks; may recur
- Wide spectrum of severity
- Classified as Erythema multiforme minor or Erythema multiforme major
Clinical Features
- Erythematous or violaceous macules, papules, vesicles, or bullae
- Target lesions with “three zones of color” are the hallmark of EM
- Distribution is usually symmetric, most commonly involving palms/soles, the backs of the hands/feet, and/or the extensor surfaces of the extremities
- Not to be confused with SJS/TEN, which are now considered separate from the EM spectrum
- Erythema multiforme minor
- Typical targets or raised, edematous papules distributed peripherally
- No mucous membrane involvement
- Erythema multiforme major
- Same as EM minor + involvement of 1+ mucous membranes
- Epidermal detachment involves < 10% of total body surface area
- Some cases can be severe or even fatal
Differential Diagnosis
- Fixed drug reaction
- Steven-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN)
- Subacute cutaneous lupus erythematosus
- Urticaria
- Viral exanthems
- Allergic or irritant contact dermatitis
Workup
- Usually made clinically
- In severe cases, work-up includes basic labs and cultures
- Punch biopsy: to confirm the diagnosis and to rule out other diagnoses (looks different from SJS/TEN histologically)
Management
- Search for underlying cause
- Prompt withdrawal of suspected drug/agent causing symptoms
- Symptomatic treatment
- Oral antihistamines, analgesics, local skin care
- If oral involvement: soothing mouth washes
- If eye involvement: topical lubricants, cleaning of conjunctiva, and removal of fresh adhesions
- Mild cases with localized lesions, may consider topical corticosteroids. Use of systemic steroids is controversial
- Consultation (rarely) with the following may be necessary: dermatologist, ophthalmologist, burn surgeon
Disposition
- For mild cases, treat as above with dermatology follow-up
- For severe cases with multiple lesions / severe mucous membrane or tracheobronchial involvement with impaired PO intake, dehydration, or secondary infection: inpatient admission
- May require specialized ICU or burn unit care