Erythema multiforme

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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
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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

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

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