Erythema multiforme

Background

  • Erythema Multiforme (EM) is an acute, self-limited skin condition
  • 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

Precipitants

  • Infections:
  • 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

Clinical Features

Erythema Multiforme
Erythema multiforme minor of the hand (note of make of the blanching centers of the lesion)
  • 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
  1. Erythema multiforme minor
    1. Typical targets or raised, edematous papules distributed peripherally
    2. No mucous membrane involvement
  2. Erythema multiforme major
    1. Same as EM minor + involvement of 1+ mucous membranes
    2. Epidermal detachment involves < 10% of total body surface area
    3. Some cases can be severe or even fatal

Differential Diagnosis

Vesiculobullous rashes

Febrile

Afebrile

Evaluation

  • 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

See Also

External Links

References

  1. ↑ Lamoreux MR, Sternbach MR, Hsu WT (December 2006). Erythema multiforme. Am Fam Physician 74 (11): 1883–8. PMID 17168345
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