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Good Morning!!
Morning Report: Thursday, April 19th
Erythema Multiforme
Some Background Info…
 EM is an acute, immune-mediated condition
characterized by the appearance of distinctive
target-like lesions on the skin, often accompanied
by erosions or bullae involving the oral, genital,
and/or the ocular mucosae
 EM major: EM with mucosal involvement
 EM minor: EM without mucosal involvement
 EM major and SJS are different diseases with
distinct causes
Epidemiology
 Incidence <1%
 Occurs most frequently in young adults (b/t 20-40
yo)
 Slight male predominance
Etiology
 Infections
 Medications
 Malignancy
 AI disease
 Immunizations
 Radiation
 Sarcoidosis
 Menstruation
Etiology
 Infections (90%)
 HSV
 Mycoplasma pneumoniae*
 Medications (<10%)
 NSAIDs
 Sulfonamides
 Antiepileptics
 Antibiotics
Pathogenesis
 Cell-mediated immune process directed against
viral antigens deposited in lesional skin
 Genetic susceptibility
Cutaneous Features
Mucous Membrane Involvement
Systemic Symptoms
 Uncommon in mild cases of EM, but can be seen
in cases with significant mucosal involvement
 Fever
 Malaise
 Myalgias
 Cough and respiratory symptoms (EM related to
Mycoplasma)
Evaluation
 Labs
 Non-specific findings:
• Elevated ESR
• Elevated WBC ct
• Elevated liver enzymes
 If any suspicion, may test for:
• HSV (DFA, viral Cx, PCR)
• M. pneumoniae (serology)
 Skin biopsy
 If diagnosis is in question
Epidermal cell apoptosis, basal cell
vacuolar degeneration, lymphocytic
exocytosis, and a dermal lymphocytic
infiltrate are present.
Disease Course
 HSV-associated EM lesions usually appear 2-17
days after an outbreak (avg. 8 days)
 Lesions appear over 3-5 days and disappear over
~2 weeks (self-limited)
 Usually do not scar, but may leave an area of
postinflammatory hyperpigmentation that may
remain for months
Disease Course
 Recurrent EM
 Frequent episodes over many years
 Most cases due to HSV infection
 Persistent EM
 Uninterrupted occurrence of typical and atypical EM
lesions
Treatment
 Varies according to severity:
 Mild
• Symptomatic treatment
• Topical corticosteroids
• Oral antihistamines
• MMW
 Severe
• Supportive care
• Nutrition/ hydration
• Pain control
• ?Oral glucocorticoids
• Ophthalmology exam
Treatment
 Inciting agents
 Little data on the effect of acute treatment of inciting
infection on the severity or duration of EM
• Two case series show treatment with oral antivirals after the
appearance of HSV-associated EM does NOT affect the clinical
course
• No formal studies on the effect of treatment of other infectious
causes of EM
 Treatment should be instituted as appropriate for
management of active infection
A Question…
 You are evaluating a 7 yo girl with a 2 day h/o rash
without fever or other symptoms. The only notable
finding on PE are round, erythematous, thin plaques,
each of which has a central violaceous discoloration or
blister. The lesions are concentrated on the
extremities, including the hands and feet, with relative
sparing of the trunk. Of the following, the most likely
diagnosis is:
 A. Erythema migrans
 B. Erythema multiforme
 C. SJS
 D. TEN
 E. Urticaria
Thanks for your
attention!!
Noon Conference: Dr. Dawkins, Toddler GU
Issues