Contents

Search

erythema multiforme

Self-limited mucocutaneous reaction. Etiology: 1) systemic infection (~50%) [5] a) Herpes simplex (especially recurrent erythema multiforme minor) b) Mycoplasma pneumoniae c) Yersinia enterocolitica 2) sensitivity to pharmacologic agent (~50%) [5] a) NSAIDs - phenylbutazone - salicylates b) anticonvulsants - barbiturates - phenytoin c) sulfonamides d) antibotics - penicillins - tetracyclines d) thiazides e) chlorpropamide f) codeine g) sulfones h) allopurinol 3) pregnancy 4) food allergy 5) X-rays 6) cancer 7) connective tissue disease 8) inflammatory bowel disease Epidemiology: 1) adolescents & young adults 2) more frequent in males than females Pathology: 1) dermal blood vessel involvement 2) extravasation of erythrocytes with resultant purpura 3) perivascular mononuclear infiltrate 4) edema of the upper dermis 5) eosinophilic necrosis of keratinocytes with subepidermal bulla formation 6) toxic epidermal necrolysis (TEN) in severe cases Clinical manifestations: 1) mucous membrane manifestations (70%) - mucosal erosion - painful - lips, oropharynx, nasal, conjunctival, vulvar, anal - sudden appearance - pharyngitis - vulvitis & balanitis may interfere with micturition - cheilitis & stomatitis may interfere with eating 2) skin manifestations - erythematous plaques on skin &/or mucous membranes - sudden appearance - sharply demarcated - symmetric distribution - "target lesions" (3 zones) resulting from papule or vesicle formation in the center of a plaque - resolution without scarring - lesions may last up to 2 weeks - predilection for dorsum of hands, palms & soles, feet, face, elbows, knees, penis (50%) & vulva - pruritus - positive Nikolsky sign in more severe forms 3) other manifestations a) systemic symptoms in more severe forms - mild fever - arthralgias - myalgias - malaise b) eye manifestations - anterior uveitis - corneal ulcers - conjunctivitis 4) often recurrent 5) severe life-threatening variant - necrotizing tracheobronchitis - meningitis - renal tubular necrosis - Stevens-Johnson syndrome -> toxic epidermal necrolysis * images [7,8,10] Differential diagnosis: 1) acute erythematous plaques a) drug eruption b) psoriasis c) secondary syphilis d) urticaria 2) acute oral erosions a) Herpes b) pemphigus c) lupus erythematosus 3) annular lesions a) erythema migrans of Lyme disease b) herald patch of Pityriasis rosea c) Tinea corporis Complications: - secondary bacterial infection which may result in scarring especially on mucous membranes of eyes & urethra - not fatal [5] Management: 1) supportive care 2) acyclovir for control of Herpes simplex a) does not shorten duration of symptoms b) chronic suppressive therapy may diminish recurrence 3) treatment & prevention of bacterial infection - azithromycin for pneumonia due to Mycoplasma pneumoniae ' - penicillin for secondary syphilis 4) prednisone 50-80 mg PO QD in divided doses, rapidly tapered a) no controlled studies b) reserve for severely ill patients c) not effective; do not use [5]

Interactions

disease interactions

Related

acyclovir (ACV, Zovirax, Sitavig) erythema nodosum (septal panniculitis) Herpes simplex (HSV) or Herpes hominis Nikolsky's sign pemphigus prednisone (Deltasone, Orasone, Liquid Pred, Meticortin, Rayos) psoriasis Stevens-Johnson syndrome (SJS) syphilis systemic lupus erythematosus toxic (bullous) epidermal necrolysis (Lyell syndrome, TEN) urticaria (hives)

General

vesiculobullous dermatitis

References

  1. Harrison's Principles of Internal Medicine, 13th ed. Companion Handbook, Isselbacher et al (eds), McGraw-Hill Inc. NY, 1995, pg 829-39
  2. DeGowin & DeGowin's Diagnostic Examination, 6th edition, RL DeGowin (ed), McGraw Hill, NY 1994, pg 883
  3. Color Atlas and Synopsis of Clinical Dermatology, Common and Serious Diseases, 3rd ed, Fitzpatrick et al, McGraw Hill, NY, 1997, pg 332-35
  4. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 169
  5. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16, 17, 18. American College of Physicians, Philadelphia 1998, 2006, 2009, 2012, 2015, 2018. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  6. Scully C, Bagan J. Oral mucosal diseases: erythema multiforme. Br J Oral Maxillofac Surg. 2008 Mar;46(2):90-5. Epub 2007 Sep 4. PMID: 17767983
  7. Plaza JA, James WD (images) Medscape: Erythema Multiforme http://emedicine.medscape.com/article/1122915-overview
  8. DermNet NZ. Erythema multiforme (images) http://dermnetnz.org/reactions/erythema-multiforme.html
  9. Stoopler ET, Houston AM, Chmieliauskaite M, Sollecito TP. Erythema Multiforme. J Emerg Med. 2015 Dec;49(6):e197-8. PMID: 26281815
  10. Puerta-Pena M, Velasco-Tamariz V. Images in Clinical Medicine. Herpes-Associated Erythema Multiforme. N Engl J Med 2021; 384:1848. May 13 PMID: 33979491 https://www.nejm.org/doi/full/10.1056/NEJMicm2033090