Updated: 12/17/2021

Erythema Multiforme

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  • Snapshot
    • A 33-year-old male presents to his physician complaining of several red lesions on his palms, back of hands, and on his lips. His past medical history is significant for recurrent herpes.
  • Introduction
    • Hypersensitivity reaction of the skin
    • Common, acute mucocutaneous disease with classic target-shaped lesions with symmetric distribution
    • Divided into erythema multiforme (EM) major and minor
      • major: involves mucous membranes and systemic signs
      • minor: no mucous membrane involvement and no systemic signs
    • Causes
      • most common = infection
        • Herpes simplex virus (most common cause)
        • Mycoplasma pneumonia
        • upper respiratory infections
      • less common = drugs
        • e.g., sulfonamides, β-lactams, phenytoin
      • idiopathic
    • Often affects young adults (18 - 30 years old especially)
    • Distinct from SJS/TEN, which is a more severe mucocutaneous reaction that is usually caused by a medication
  • Presentation
    • Skin
      • raised (papular), target lesions with multiple rings and dusky center (as opposed to annular lesions in urticaria)
        • three concentric zones of color from center to outer ring
          • central dusky/dark area that can be crust or vesicle
          • paler pink or edematous zone
          • peripheral red/dark ring
      • fixed lesions (as opposed to urticaria, in which lesions typically resolve within 24 hours)
      • negative Nikolsky sign (as opposed to SJS/TEN)
      • generally mild burning or itchiness; nontender
      • most commonly involves
        • palms/soles
        • backs of hands and feet
        • extensor aspects of forearms and legs
    • Must also examine mucosal surfaces and eyes
      • oral
      • genital/anal
      • iris
    • May have systemic signs (e.g., fever, prodrome)
  • Evaluation
    • Diagnosis is based on symptoms and clinical history
      • recent history of infection (e.g., herpes or mycoplasma) can aid diagnosis
  • Differential
    • SJS/TEN (flat lesions, tender, always with mucous involvement, + Nikolsky sign)
    • Urticaria (annular lesions)
    • Erythema nodosum
    • Viral exanthems
  • Treatment
    • EM major
      • corticosteroids
      • opthalmology consult if ocular involvement
    • EM minor – usually self-limited
      • supportive care
    • Treat underlying cause if identified
      • oral acyclovir for HSV
  • Prevention
    • Prevention
      • treat chronic herpes infections
      • if recurrent herpes associated-EM
        • oral acyclovir, valcyclovir, or famciclovir as continuous suppressive therapy
  • Complications
    • Usually none associated with EM minor
    • Potential ocular complications with EM major
  • Prognosis
    • Typically self-limited
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