Erythema multiforme: Difference between revisions
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==Background==
==Background==
[[File:EM_picture.jpeg|thumb|Erythema Multiforme]]
{{Skin anatomy background images}}
 
*Erythema Multiforme (EM) is an acute, self-limited skin condition  
*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
*Peak incidence in second and third decades of life
*Peak incidence in second and third decades of life
*Despite multiple associations, thought to be triggered by HSV in most cases
*Despite multiple associations, thought to be triggered by [[HSV]] in most cases
*Usually self-limited and resolves within 2-6 weeks; may recur
*Usually self-limited and resolves within 2-6 weeks; may recur
*Wide spectrum of severity
*Wide spectrum of severity
**Classified as Erythema multiforme minor or Erythema multiforme major
**Classified as Erythema multiforme minor (skin involvement only) or Erythema multiforme major (involves skin and one or more mucous membranes)
 
===Precipitants===
*Infections:
**Viral: [[HSV]], [[hepatitis]], [[influenza]] A
***HSV responsible for ~70% of cases, making it the most common etiology<ref>Lamoreux MR, Sternbach MR, Hsu WT (December 2006). '''Erythema multiforme'''. ''Am Fam Physician 74'' (11): 1883–8. PMID 17168345</ref>
**Fungal: [[dermatophytosis]], [[histoplasmosis]], [[coccidioidomycosis]]
**Bacterial: [[streptococcus]], [[mycoplasma]], [[tuberculosis]]
*Drugs:
**Antibiotics ([[penicillin]], sulfonamides), [[anticonvulsants]] ([[phenytoin]], [[barbiturates]]), [[NSAIDS]], [[aspirin]], anti-[[tuberculosis]] meds, [[allopurinol]], etc.
*Collagen Vascular Disorders:
**[[RA]], [[SLE]], [[dermatomyositis]], [[polyarteritis nodosa]]
*Others:
**[[Pregnancy]], cold weather, sunlight, contact exposure, foods, malignancy, hormonal


==Clinical Features==
==Clinical Features==
[[File:EM_picture.jpeg|thumb|Erythema Multiforme]]
[[File:Erythema multiforme minor of the hand.jpg|thumb|Erythema multiforme minor of the hand (note of make of the blanching centers of the lesion)]]
[[File:Erythema multiforme minor of the hand.jpg|thumb|Erythema multiforme minor of the hand (note of make of the blanching centers of the lesion)]]
*Erythematous or violaceous macules, papules, vesicles, or bullae
*Erythematous or violaceous [[rash|macules, papules, vesicles, or bullae]]
*Target lesions with “three zones of color” are the hallmark of EM
*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   
*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
*Not to be confused with [[SJS|SJS/TEN]], which are now considered separate from the EM spectrum


#Erythema multiforme minor
===Erythema multiforme minor===
##Typical targets or raised, edematous papules distributed peripherally
*Typical targets or raised, edematous papules distributed peripherally
##No mucous membrane involvement
*No mucous membrane involvement
#Erythema multiforme major
 
##Same as EM minor + involvement of 1+ mucous membranes
===Erythema multiforme major===
##Epidermal detachment involves < 10% of total body surface area  
*Same as EM minor + involvement of 1+ mucous membranes
##Some cases can be severe or even fatal
*Epidermal detachment involves < 10% of total body surface area  
*Some cases can be severe or even fatal


==Differential Diagnosis==
==Differential Diagnosis==
*Fixed drug reaction
{{Erythematous rash DDX}}
*[[Stevens Johnson Syndrome and Toxic Epidermal Necrolysis]]
{{Bullous rashes DDX}}
*Subacute cutaneous lupus erythematosus
*[[Urticaria]]
*Viral exanthems
*Allergic or irritant contact dermatitis


==Workup==
==Evaluation==
*Usually made clinically
*Usually made clinically
*In severe cases, work-up includes basic labs and cultures
*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)
*Punch biopsy: to confirm the diagnosis and to rule out other diagnoses (looks different from [[SJS/TEN]] histologically)


==Management==
==Management==
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**Prompt withdrawal of suspected drug/agent causing symptoms
**Prompt withdrawal of suspected drug/agent causing symptoms
*Symptomatic treatment
*Symptomatic treatment
**Oral antihistamines, analgesics, local skin care
**Systemic [[corticosteroids]]
**Oral [[antihistamines]], [[analgesia|analgesics]], local skin care
**If oral involvement: soothing mouth washes
**If oral involvement: soothing mouth washes
**If eye involvement: topical lubricants, cleaning of conjunctiva, and removal of fresh adhesions
**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
**Mild cases with localized lesions, may consider [[topical corticosteroids]].  
*Consultation (rarely) with the following may be necessary: dermatologist, ophthalmologist, burn surgeon
*Consultation (rarely) with the following may be necessary: dermatologist, ophthalmologist, burn surgeon


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==See Also==
==See Also==
*[[Generalized rashes]]


==External Links==
==External Links==


==Sources==
==References==
*Plaza J, Prieto V.  Erythema Multiforme. Medscape fromWebMD. Sept 2014
*Plaza J, Prieto V.  Erythema Multiforme. Medscape fromWebMD. Sept 2014
*Rosen’s Emergency Medicine
*Rosen’s Emergency Medicine
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*http://www.ncbi.nlm.nih.gov/pubmed/18723713
*http://www.ncbi.nlm.nih.gov/pubmed/18723713
*Image source: Weinberg A, Prose N, Kristal L.  Color Atlas of Pediatric Dermatology.  McGraw-Hill  Companies, Inc. Copyright 2008, 1998, 1990, 1975
*Image source: Weinberg A, Prose N, Kristal L.  Color Atlas of Pediatric Dermatology.  McGraw-Hill  Companies, Inc. Copyright 2008, 1998, 1990, 1975
 
<references/>
[[Category:Derm]]
[[Category:Dermatology]]

Latest revision as of 16:23, 11 December 2024

Background

Normal dermal anatomy.
  • 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 (skin involvement only) or Erythema multiforme major (involves skin and one or more mucous membranes)

Precipitants

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

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

Erythematous rash

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
  • 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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