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Jeyanthikumari T, Thayumanavan B, Mohideen K, Vinayakam S, Ghosh S, Dhungel S. Oral Manifestation of Viral-Induced Erythema Multiforme Major: A Rare Presentation. Indian J Otolaryngol Head Neck Surg 2024; 76:1164-1167. [PMID: 38440462 PMCID: PMC10908995 DOI: 10.1007/s12070-023-04195-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 08/24/2023] [Indexed: 03/06/2024] Open
Abstract
Erythema multiforme is an acute inflammatory mucocutaneous disease manifested as macules, vesicles, bullae, erosion, and papular lesions. In the present case, a 55-year-old female patient reported painful growth in the oral cavity and difficulty in mastication. The patient gave a history of prodromal symptoms before the onset of lesions On intra-oral examination, elevated plaque-like lesions were present bilaterally on lateral borders of the tongue and buccal mucosa near the retromolar region. Extraoral examination revealed concentric erythematous target (or) bull's eye lesions in palms, forearm, and foot. Based on history, clinical examination, and laboratory investigations, recurrent herpes-associated erythema multiforme was diagnosed. We report a rare clinical presentation of recurrent herpes-associated erythema multiforme manifesting as an extensive plaque-like lesion intra-orally.
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Affiliation(s)
- T Jeyanthikumari
- Government Dental College and Hospital, Chennai, Tamil Nadu India
| | | | - Khadijah Mohideen
- Department of Oral Pathology and Microbiology, Sathyabama Dental College and Hospital, Sathyabama Institute of Science and Technology, Chennai, India
| | - S Vinayakam
- Tamilnadu Government Dental College, Chennai, India
| | - Snehashish Ghosh
- Department of Oral Pathology, College of Medical Sciences, Bharatpur, Nepal
| | - Safal Dhungel
- Department of Oral and Maxillofacial Surgery, College of Medical Sciences, Bharatpur, Nepal
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2
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Lee JM, Lee YJ, Choi YJ, Lee JH, Choi JE, Han TY. A case of persistent erythema multiforme treated with upadacitinib. J Dermatol 2024; 51:e3-e5. [PMID: 37641556 DOI: 10.1111/1346-8138.16938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/29/2023] [Accepted: 08/12/2023] [Indexed: 08/31/2023]
Affiliation(s)
- Jung Min Lee
- Department of Dermatology, Nowon Eulji Medical Center, Eulji University, Seoul, South Korea
| | - Yu Jin Lee
- Department of Dermatology, Nowon Eulji Medical Center, Eulji University, Seoul, South Korea
| | - Yun Jeong Choi
- Department of Dermatology, Nowon Eulji Medical Center, Eulji University, Seoul, South Korea
| | - June Hyunkyung Lee
- Department of Dermatology, Nowon Eulji Medical Center, Eulji University, Seoul, South Korea
| | - Jae Eun Choi
- Department of Dermatology, Nowon Eulji Medical Center, Eulji University, Seoul, South Korea
| | - Tae Young Han
- Department of Dermatology, Nowon Eulji Medical Center, Eulji University, Seoul, South Korea
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3
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Kim JC, Kang SY, Chung BY, Park CW, Kim HO. Case Report: Erythema Multiforme Induced by Lithium Contact. Ann Dermatol 2023; 35:S225-S228. [PMID: 38061709 PMCID: PMC10727867 DOI: 10.5021/ad.21.191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 01/13/2022] [Accepted: 01/24/2022] [Indexed: 12/20/2023] Open
Abstract
Erythema multiforme (EM) is an acute, self-limited mucocutaneous disease with diverse triggering factors, and the recurrences are quite common. A 24-year old male presented with multiple erythematous, itchy papules and plaques on multiple sites. He has worked in a lithium battery factory and experienced the chemical burn 2 weeks ago. A histopathologic examination on right wrist showed a scattered lymphocytic infiltration, vacuolar degeneration, and necrotic keratinocyte. The final diagnosis was EM after occupational lithium exposure. He was treated by oral methylprednisolone and experienced recurrences after returning to the same workplace after remission. Although the precise pathogenesis is unknown, the pathogenesis of EM by lithium is related to the effect of lithium on immune system, different from other etiologies. To our knowledge, our case is the first report of EM following the chemical burn and occupational lithium exposure. We report this as an interesting case of EM.
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Affiliation(s)
- Jin Cheol Kim
- Department of Dermatology, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Seok Young Kang
- Department of Dermatology, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Bo Young Chung
- Department of Dermatology, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Chun Wook Park
- Department of Dermatology, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Hye One Kim
- Department of Dermatology, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea.
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4
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Gemnani R, Mahajan S, Saboo K, Pradeep U, Gupta A. Erythema Multiforme: Unveiling the Unusual Effect of an Ayurvedic Medication 'Jambavasa' Used in the Treatment of Type 2 Diabetes Mellitus. Cureus 2023; 15:e43306. [PMID: 37701014 PMCID: PMC10492666 DOI: 10.7759/cureus.43306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 08/10/2023] [Indexed: 09/14/2023] Open
Abstract
Erythema multiforme (EM) is a rare immune-mediated condition that can manifest as cutaneous, mucosal, or both types of lesions. The target lesion, with concentric zones of color change, is a cutaneous feature that is typical of this illness. Despite the fact that a number of factors can lead to EM, the most common being Herpes simplex virus (HSV) infection, drug-induced EM is a rare entity. As disease severity and mucosal involvement vary across individuals, treatment should be optimized for each patient, considering the risk versus benefit ratio. To distinguish EM from other clinical imitators and to confirm the diagnosis, histopathologic tests and other laboratory procedures may be utilized. Our patient presented with symptoms suggestive of a viral infection, such as fever and rash, but the RTPCR report for various viral infections came out to be negative, hence indicative of the diagnosis of drug-induced erythema multiforme.
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Affiliation(s)
- Rinkle Gemnani
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Satish Mahajan
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Keyur Saboo
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Utkarsh Pradeep
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Aman Gupta
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Smith MH, Mintline M. Acute Immune-Mediated Lesions of the Oral Cavity. Oral Maxillofac Surg Clin North Am 2023; 35:247-259. [PMID: 37019507 DOI: 10.1016/j.coms.2022.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
Although acute immune-mediated lesions of the oral cavity (AIML) can have an onset over several months, they often demonstrate rapid onset and can be self-limited. Despite the self-limiting nature of some disorders, patients with AIML can have significant pain and multisystem involvement. It is vital for the oral health care provider to arrive at the proper diagnosis with distinction from overlapping conditions, as the oral manifestations may be harbingers of more serious systemic complications.
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Affiliation(s)
- Molly Housley Smith
- Pathology and Cytology Laboratory, 290 Big Run Road, Lexington, KY 40503, USA.
| | - Mark Mintline
- WesternU Health Oral Pathology, 701 East 2nd Street, Room 3204, Pomona, CA 91766, USA
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Suwarsa O, Dewi IP, Sutedja E, Dharmadji HP, Gunawan H, Pangastuti M. A Case Report: Clinical Efficacy of Combination Treatment of Dexamethasone and Azathioprine in Recurrent Erythema Multiforme. Int Med Case Rep J 2022; 15:355-359. [PMID: 35832787 PMCID: PMC9271803 DOI: 10.2147/imcrj.s364608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 05/25/2022] [Indexed: 11/24/2022] Open
Abstract
Recurrent erythema multiforme (REM) may have frequent episodes over a period of several years and is considered to be a hypersensitivity reaction associated with infection or medication. REM is a mucocutaneous disorder which is characterized by targetoid lesions. Most of the cases are caused by herpes simplex virus infection. Systemic corticosteroid is frequently used to treat REM due to its effects in suppressing the disease. When REM is unresponsive to systemic corticosteroid, steroid-sparing treatment needs to be instituted. We reported a case of REM in a 49-year-old male. There were complaints of burning sensations on the skin lesions, along with swelling on both hands. On physical examination, erythematous macules and targetoid lesions were found on both palms, arms, and legs. During hospitalization, dexamethasone 20 mg was administered in a tapering dose but new skin lesions still appeared. Two days after azathioprine 50 mg twice daily was added to the treatment, skin lesions and swelling on the patient’s hands were diminished and the burning sensation disappeared. No side effects of azathioprine were found in this patient and no recurrence until two weeks after hospitalization. This case report demonstrated the efficacy of combined treatment of dexamethasone and azathioprine for REM cases unresponsive to systemic corticosteroid.
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Affiliation(s)
- Oki Suwarsa
- Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran - Dr. Hasan Sadikin Hospital, Bandung, Indonesia
- Correspondence: Oki Suwarsa, Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran - Dr. Hasan Sadikin Hospital, Jl. Pasteur 38, Bandung, West Java, 40161, Indonesia, Tel +62222032426 ext. 3449, Fax +62222032426, Email
| | - Isabella Puspa Dewi
- Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran - Dr. Hasan Sadikin Hospital, Bandung, Indonesia
| | - Endang Sutedja
- Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran - Dr. Hasan Sadikin Hospital, Bandung, Indonesia
| | - Hartati Purbo Dharmadji
- Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran - Dr. Hasan Sadikin Hospital, Bandung, Indonesia
| | - Hendra Gunawan
- Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran - Dr. Hasan Sadikin Hospital, Bandung, Indonesia
| | - Miranti Pangastuti
- Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran - Dr. Hasan Sadikin Hospital, Bandung, Indonesia
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Weill A, Descamps V, Chasset F, Mahévas T, Bourgault-Villada I, Wolkenstein P, Chollet-Martin S, Ingen-Housz-Oro S, Grootenboer-Mignot S. Erythema multiforme associated with anti-plakin antibodies: a multicentric retrospective case series. J Eur Acad Dermatol Venereol 2022; 36:2438-2442. [PMID: 35607912 DOI: 10.1111/jdv.18259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 05/05/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Erythema multiforme (EM) is a muco-cutaneous inflammatory disease mainly triggered by herpes simplex virus (HSV) recurrences. Association of EM and circulating auto-antibodies against plakins (anti-PLK-Abs [EM-PLK+]) has been reported. However, little is known about this subset of EM. OBJECTIVES We aimed to describe the clinical and immunological features and response to treatment of EM-PLK+. METHODS We conducted a retrospective multicentric study of EM-PLK+ selected from the database of the immunological laboratory of Bichat hospital, Paris, France, from January 2009 to December 2020. Anti-PLK-Abs were detected in ≥1 immunological tests: immunofluorescence assay, immunoblotting and/or ELISA. Patients with alternative diagnoses were excluded. RESULTS We included 29 patients (16 women, median age 25 [range 2-58] years). EM-PLK+ were mostly major (EM with ≥2 mucosal involvements; n = 24, 83%) and relapsing (≥2 flares; n = 23, 79%). Cutaneous lesions were target (n = 13, 54%) and target-like lesions (n = 9, 38%) with usual topography (acral, n = 19, 79%; limbs, n = 21, 88%). Mucosal lesions affected the mouth (n = 27, 96%) and genitalia (n = 19, 68%), with a median of 2 [range 0-5] mucous membranes. EM-PLK+ were suspected as certain or possible postherpetic (EM-HSV) in 19 cases (65.5%); no triggering factors were detected in 9 (31%) patients. Desmoplakin-I/II Abs were the most frequent anti-PLK-Abs (n = 20, 69%); envoplakin and periplakin Abs were detected in 11 and 9 cases. Relapsing EM-PLK+ (n = 23) were still active (≥1 flare within 6 months) in 13 (57%) patients despite immunosuppressive therapy (n = 8, 62%). Antiviral drugs were ineffective in preventing relapse in 15/16 (94%) EM-HSV. CONCLUSION The rationale for anti-PLK-Ab detection in EM is not elucidated. More systematic research of anti-PLK-Abs is warranted to better understand whether this association reflects humoral immune activity in a subset of EM or is fortuitous, related to an epitope spreading process. However, EM-PLK+ seems to be associated with major and relapsing subtypes, and difficult-to-treat cases.
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Affiliation(s)
- A Weill
- Department of Dermatology, CHU Henri Mondor, AP-HP, Créteil, France.,Referral Center for Toxic Bullous Dermatoses and Severe Drug Reactions TOXIBUL, Créteil, France.,Referral Center for Auto-Immune Bullous Diseases (MALIBUL), AP-HP, Paris, France
| | - V Descamps
- Department of Dermatology, CHU Bichat, AP-HP, Paris, France
| | - F Chasset
- Faculty of Medicine, Department of Dermatology, CHU Tenon, AP-HP, Sorbonne Université, Paris, France
| | - T Mahévas
- Department of Dermatology, CHU Saint-Louis, AP-HP, Paris, France
| | - I Bourgault-Villada
- Department of Dermatology, CHU Ambroise Paré, AP-HP, Boulogne Billancourt, France
| | - P Wolkenstein
- Department of Dermatology, CHU Henri Mondor, AP-HP, Créteil, France.,Referral Center for Toxic Bullous Dermatoses and Severe Drug Reactions TOXIBUL, Créteil, France.,Referral Center for Auto-Immune Bullous Diseases (MALIBUL), AP-HP, Paris, France.,Univ Paris Est Créteil Epiderm E, Créteil, France
| | | | - S Ingen-Housz-Oro
- Department of Dermatology, CHU Henri Mondor, AP-HP, Créteil, France.,Referral Center for Toxic Bullous Dermatoses and Severe Drug Reactions TOXIBUL, Créteil, France.,Referral Center for Auto-Immune Bullous Diseases (MALIBUL), AP-HP, Paris, France.,Univ Paris Est Créteil Epiderm E, Créteil, France
| | - S Grootenboer-Mignot
- Referral Center for Auto-Immune Bullous Diseases (MALIBUL), AP-HP, Paris, France.,Department of Immunobiology, CHU Bichat, AP-HP, Paris, France
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8
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Milo RB. Differential Diagnosis of Lesions. Adv Emerg Nurs J 2022; 44:23-28. [PMID: 35089277 DOI: 10.1097/tme.0000000000000388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
There have been many uncertainties during the coronavirus pandemic. New studies emerge about new symptoms associated with the virus that include dermatological disorders. Lesions with an unknown cause can be a challenge to diagnose and treat. Some lesions have nonspecific symptoms associated with viral infections, immune-mediated reactions, autoimmune disease, malignancy, radiation, immunizations, and sarcoidosis. These lesions may be associated with erosions and bullae that can involve the mucosa. Nurse practitioners must be aware of the clinical manifestations of various lesions and need to determine when patients should be hospitalized or managed in the outpatient setting.
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Affiliation(s)
- Razel B Milo
- Hahn School of Nursing and Health Science, Beyster Institute for Nursing Research, University of San Diego, San Diego, California
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9
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Diagnosis and Management of Oral Extraintestinal Manifestations of Pediatric Inflammatory Bowel Disease. J Pediatr Gastroenterol Nutr 2022; 74:7-12. [PMID: 34560727 PMCID: PMC8714692 DOI: 10.1097/mpg.0000000000003302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
ABSTRACT Inflammatory bowel diseases (IBD) represent a group of chronic inflammatory disorders of the gastrointestinal tract that lead to impaired quality of life and substantial health care costs. Up to 50% of pediatric IBD cases present with manifestations in the oral cavity. These may develop in nearly every oral tissue, including the soft tissues, tongue, lips, teeth, and lymph nodes. The goal of this review is to offer a systematic approach to diagnose and manage commonly encountered oral manifestations of pediatric IBD. This knowledge is critical for enhancing the comprehensive care and quality of life of children with these debilitating diseases.
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10
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Murphy MJ, Gruenstein D, Wang A, Peterson D, Levitt J, King B, Damsky W. Treatment of Persistent Erythema Multiforme With Janus Kinase Inhibition and the Role of Interferon Gamma and Interleukin 15 in Its Pathogenesis. JAMA Dermatol 2021; 157:1477-1482. [PMID: 34757416 PMCID: PMC8581795 DOI: 10.1001/jamadermatol.2021.4084] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 09/06/2021] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Persistent erythema multiforme (PEM) is poorly understood and lacks effective therapies other than glucocorticoids. OBJECTIVE To report outcomes following treatment of PEM with Janus kinase (JAK) inhibition and to elucidate cytokine drivers of erythema multiforme (EM). DESIGN, SETTING, AND PARTICIPANTS This was a retrospective case series of 4 patients with PEM treated with tofacitinib and/or upadacitinib in 2015 to 2021 at the dermatology clinics of 2 major tertiary referral centers. Four consecutive patients with PEM refractory to multiple treatment approaches were treated. In 1 patient, skin biopsy specimens were obtained for RNA sequencing and proteomic analysis before and during treatment. Molecular findings were validated through RNA in situ hybridization analysis of cytokine expression in biopsy specimens from a total of 12 patients with EM (3 treated with tofacitinib in this study and 9 historic samples). INTERVENTIONS Treatment with tofacitinib, 5 to 10 mg, twice daily or upadacitinib, 15 mg, once daily. MAIN OUTCOMES AND MEASURES Change in PEM activity was assessed in all 4 patients treated with a JAK inhibitor. Median (range) follow-up was 20.5 months (10.0-36.0 mo). RESULTS The study population of 4 female patients had a mean (SD) age of 46.2 (13.7) years and a mean (SD) disease duration of 21.75 (11.30) years. Marked clinical improvement was noted in all 4 patients. In 1 patient with a robust improvement following treatment with tofacitinib, RNA sequencing identified interferon gamma (IFN-γ) and interleukin 15 (IL-15) as cytokines with activity both highly upregulated at baseline in lesional skin and subsequently suppressed following tofacitinib treatment. Measurement of IFNG- and IL15-positive cells in additional EM biopsy specimens of 12 patients showed significant upregulation of IFNG (8.72 cells per mm; 95% CI, 2.60-14.84) and IL15 (14.13 cells per mm; 95% CI, 0.14-28.11) compared with normal skin (P = .008 and P = .045, respectively). CONCLUSIONS AND RELEVANCE The results of this case series study suggest that JAK inhibition may be effective in treating PEM and that IFN-γ and IL-15 may be important cytokine mediators of the disease.
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Affiliation(s)
- Michael J. Murphy
- Department of Dermatology, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Diana Gruenstein
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alice Wang
- Department of Dermatology, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Danielle Peterson
- Department of Dermatology, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Jacob Levitt
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Brett King
- Department of Dermatology, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - William Damsky
- Department of Dermatology, Yale School of Medicine, Yale University, New Haven, Connecticut
- Department of Pathology, Yale School of Medicine, Yale University, New Haven, Connecticut
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11
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Dominguez AR, Lopez SN. Novel Treatments for Chronic Erythema Multiforme Inform Translational Science and Disease Pathogenesis. JAMA Dermatol 2021; 157:1411-1413. [PMID: 34757395 DOI: 10.1001/jamadermatol.2021.4082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Arturo R Dominguez
- Departments of Dermatology and Internal Medicine, The University of Texas Southwestern Medical Center, Dallas
| | - Samantha N Lopez
- University of Texas Southwestern Medical School, The University of Texas Southwestern Medical Center, Dallas
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12
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Roux C, Sbidian E, Bouaziz JD, Kottler D, Joly P, Descamps V, Prost C, Samimi M, Seneschal J, Dupin N, Girard C, Paul M, Le Cleach L, Ingen-Housz-Oro S. Evaluation of Thalidomide Treatment of Patients With Chronic Erythema Multiforme: A Multicenter Retrospective Cohort Study. JAMA Dermatol 2021; 157:1472-1476. [PMID: 34757396 DOI: 10.1001/jamadermatol.2021.4083] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Importance Erythema multiforme (EM) may become long term, with a recurrent or persistent course. First-line treatment for chronic EM is valaciclovir. There is no consensus for selection of second-line treatment of chronic EM. Objective The aim of this study was to assess the effectiveness of treatment with thalidomide for patients with chronic EM. Design, Setting, and Participants In this retrospective national multicenter cohort study, among 68 French hospital dermatology departments contacted by e-mail, 10 reported having eligible cases. All adults aged 18 years or older under dermatology care for chronic EM (including recurrent and persistent forms) who had received thalidomide between 2010 and 2018 were included. Analyses were conducted from June 24, 2019, to December 31, 2019. Main Outcomes and Measures The primary outcome was the proportion of patients who did not experience an EM flare within 6 months of initiating thalidomide treatment for recurrent EM or with complete clearance at 6 months for persistent EM (complete remission). Results Overall, 35 patients with chronic EM (median [range] age, 33 [15-65] years; 20 [57%] female) experienced failure of at least 1 previous treatment prior to initiating treatment with thalidomide. After 6 months of continuous thalidomide treatment, 23 (66%) were in complete remission, 5 (14%) had stopped the treatment, and 7 (20%) experienced at least 1 flare. The median (IQR) initial dose followed by remission was 50 (50-100) mg/d. Main adverse effects were asthenia (16 [46%]) and neuropathy (14 [40%]). Twenty-five (71%) of patients stopped thalidomide treatment after a median (IQR) of 12 (8-20) months owing to lack of effect (7/25 [28%]), neuropathy or another adverse effect (14/25 [56%]), or long-term complete remission (4/25 [16%]). Low-dose thalidomide, less than 50 mg every other day was sufficient in 9 of 23 (39%) of responders and was associated with less neuropathy and longer treatment duration. Conclusions and Relevance In this cohort study, second-line therapy with thalidomide was associated with complete remission in two-thirds of the 35 patients with chronic EM. However, adverse events were a common cause of thalidomide withdrawal. In the long term, dose reduction when possible may allow for continuation by improving tolerance.
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Affiliation(s)
- Camille Roux
- Department of Dermatology, Henri Mondor Hospital, AP-HP, Créteil, France
| | - Emilie Sbidian
- Department of Dermatology, Henri Mondor Hospital, AP-HP, Créteil, France.,Université Paris Est Créteil EpiDermE, Créteil, France
| | - Jean-David Bouaziz
- Department of Dermatology, Saint-Louis Hospital, AP-HP, Université de Paris, Paris, France
| | - Diane Kottler
- Department of Dermatology, Bichat Hospital, AP-HP, Université de Paris, Paris, France.,Department of Dermatology, Caen University Hospital, Caen, France
| | - Pascal Joly
- Department of Dermatology, Rouen University Hospital and INSERM 1234, Normandie University, Rouen, France
| | - Vincent Descamps
- Department of Dermatology, Bichat Hospital, AP-HP, Université de Paris, Paris, France.,Department of Dermatology, Caen University Hospital, Caen, France
| | - Catherine Prost
- Department of Dermatology, Avicenne Hospital, AP-HP, Bobigny, France
| | - Mahtab Samimi
- Department of Dermatology, University Hospital of Tours, Tours, France
| | - Julien Seneschal
- Department of Dermatology, National Reference Center for Rare Skin Diseases, Université Bordeaux, Bordeaux, France
| | - Nicolas Dupin
- Department of Dermatology, Cochin Hospital, AP-HP, Paris, France
| | - Céline Girard
- Department of Dermatology, Montpellier University Hospital, Montpellier, France
| | - Muriel Paul
- Université Paris Est Créteil EpiDermE, Créteil, France.,Department of Hospital Pharmacy, Henri Mondor Hospital, AP-HP, Créteil, France
| | - Laurence Le Cleach
- Department of Dermatology, Henri Mondor Hospital, AP-HP, Créteil, France.,Université Paris Est Créteil EpiDermE, Créteil, France
| | - Saskia Ingen-Housz-Oro
- Department of Dermatology, Henri Mondor Hospital, AP-HP, Créteil, France.,Université Paris Est Créteil EpiDermE, Créteil, France.,Reference Center for toxic bullous dermatoses and severe drug reactions TOXIBUL, Créteil, France
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13
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Erythema multiforme in the esophagus. Acta Gastroenterol Belg 2021. [DOI: 10.51821/83.4.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Erythema multiforme is an immune-mediated mucocutaneous disorder. Mucosal involvement usually affects the oral region, the genitals or the eyes. We report a case of esophagitis caused by erythema multiforme in a patient diagnosed with lung cancer. Esophageal manifestation in erythema multiforme is rarely seen. Besides esophagitis it can lead to esophageal strictures. Erythema multiforme is mostly triggered by infection or drugs but the association with malignancy has been described.
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14
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Soares A, Sokumbi O. Recent Updates in the Treatment of Erythema Multiforme. MEDICINA-LITHUANIA 2021; 57:medicina57090921. [PMID: 34577844 PMCID: PMC8467974 DOI: 10.3390/medicina57090921] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 08/23/2021] [Accepted: 08/27/2021] [Indexed: 02/07/2023]
Abstract
Erythema multiforme (EM) is an immune-mediated condition that classically presents with discrete targetoid lesions and can involve both mucosal and cutaneous sites. While EM is typically preceded by viral infections, most notably herpes simplex virus (HSV), and certain medications, a large portion of cases are due to an unidentifiable cause. EM can be confused with other more serious conditions like Stevens–Johnson syndrome (SJS); however, clinical research has provided significant evidence to classify EM and SJS as separate disorders. Treatment of EM is highly variable, depending on the etiology, the involvement of mucosal sites, and the chronicity (acute vs. recurring) of the disease. If the etiology or causal medication/infection is identified, then the medication is stopped and/or the infection is treated prior to initiating symptomatic treatment. Treatment for acute EM is focused on relieving symptoms with topical steroids or antihistamines. Treatment for recurrent EM is most successful when tailored to individual patients. First line treatment for recurrent EM includes both systemic and topical therapies. Systemic therapies include corticosteroid therapy and antiviral prophylaxis. Topical therapies include high-potency corticosteroids, and antiseptic or anesthetic solutions for mucosal involvement. Second-line therapies for patients who do not respond to antiviral medications include immunosuppressive agents, antibiotics, anthelmintics, and antimalarials
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Affiliation(s)
- Alexa Soares
- Mayo Clinic Alix School of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA;
| | - Olayemi Sokumbi
- Department of Dermatology, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL 32224, USA
- Correspondence: ; Tel.: +1-904-953-6402
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15
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Zhang M, Zhang M, Ju M, Xu H. A woman with recurrent erythema and vesicles on her legs. BMJ 2021; 374:n1494. [PMID: 34289972 DOI: 10.1136/bmj.n1494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Min Zhang
- Institute of Dermatology, Chinese Academy of Medical Science and Peking Union Medical College, Nanjing, Jiangsu, China
| | - Mengli Zhang
- Institute of Dermatology, Chinese Academy of Medical Science and Peking Union Medical College, Nanjing, Jiangsu, China
| | - Mei Ju
- Institute of Dermatology, Chinese Academy of Medical Science and Peking Union Medical College, Nanjing, Jiangsu, China
| | - Haoxiang Xu
- Institute of Dermatology, Chinese Academy of Medical Science and Peking Union Medical College, Nanjing, Jiangsu, China
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16
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Dias de Oliveira NF, Miyamoto D, Maruta CW, Aoki V, Santi CG. Recurrent erythema multiforme: A therapeutic proposal for a chronic disease. J Dermatol 2021; 48:1569-1573. [PMID: 34223646 DOI: 10.1111/1346-8138.16046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 05/26/2021] [Accepted: 06/05/2021] [Indexed: 11/28/2022]
Abstract
Recurrent erythema multiforme is a chronic relapsing disease that represents a therapeutic challenge. Our objective was to retrospectively evaluate the clinical-epidemiological characteristics and therapeutic response of patients with recurrent erythema multiforme and suggest a therapeutic protocol. We included patients with recurrent erythema multiforme diagnosed between January 2000 and December 2019. Clinical symptoms and a positive serology for herpes simplex virus were the inclusion criteria to initiate acyclovir in monotherapy or a combined treatment with dapsone, thalidomide, or immunosuppressants in refractory cases. Thirty-five patients were included and 71.4% were female. The median disease onset age was 35.7 years and the mean follow-up was 7.58 years. The skin was the most affected site (91.4%). Herpes simplex virus immunoglobulin (Ig)G serology was positive in 91.1% of cases. Acyclovir treatment was used in 33 of 35 patients, and complete remission was achieved in 22 of 33 after the first therapeutic course; 16 of 22 relapsed and required a second acyclovir cycle. Combined treatment with dapsone was required in nine of 33 due to partial response to acyclovir; thalidomide was an adjuvant drug in four of 33 due to adverse effects to dapsone. After the first cycle of acyclovir with or without combined therapy, 19 of 33 patients relapsed and received 2-6 additional cycles. Our results suggest that recurrent erythema multiforme presents a good response to acyclovir in monotherapy or in combined therapy with dapsone or thalidomide in the majority of patients. We propose a long-term therapeutic protocol to enable disease remission.
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Affiliation(s)
| | - Denise Miyamoto
- Department of Dermatology, University of São Paulo Medical School, Sao Paulo, Brazil
| | | | - Valeria Aoki
- Department of Dermatology, University of São Paulo Medical School, Sao Paulo, Brazil
| | - Claudia Giuli Santi
- Department of Dermatology, University of São Paulo Medical School, Sao Paulo, Brazil
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17
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Erythema multiforme in the esophagus. Acta Gastroenterol Belg 2021; 84:513-515. [PMID: 34599579 DOI: 10.51821/84.3.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Erythema multiforme is an immune-mediated mucocutaneous disorder. Mucosal involvement usually affects the oral region, the genitals or the eyes. We report a case of esophagitis caused by erythema multiforme in a patient diagnosed with lung cancer. Esophageal manifestation in erythema multiforme is rarely seen. Besides esophagitis it can lead to esophageal strictures. Erythema multiforme is mostly triggered by infection or drugs but the association with malignancy has been described.
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18
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Erythema Multiforme Attributable to Herpes Simplex Virus: Clinical Aspects and Treatment. Case Rep Dent 2021; 2021:6692495. [PMID: 34055423 PMCID: PMC8131160 DOI: 10.1155/2021/6692495] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 02/18/2021] [Accepted: 05/02/2021] [Indexed: 11/24/2022] Open
Abstract
Erythema multiforme is an acute mucocutaneous hypersensitivity reaction with various etiological factors, including herpes simplex virus, medications, autoimmune diseases, and malignancies, but the most common cause is infection by herpes simplex virus. The most characteristic feature is the presence of “target lesions.” There are no specific diagnostic tests for EM, and the diagnosis is based on clinical signs and symptoms and biopsy if required. We report a case of recurrent herpes-associated erythema multiforme managed with prophylactic acyclovir for 6 months: a 17-year-old boy had recurrent cutaneous lesions as well as lesions in the oral cavity and lips. Positive serology for herpes simplex virus and histopathological examination confirmed the diagnosis.
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19
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Fernando SL. Sifting through the history of the nosology of erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis and its clinicopathological relevance. Int J Dermatol 2020; 60:110-112. [PMID: 33252777 DOI: 10.1111/ijd.15284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 08/20/2020] [Accepted: 10/06/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Suran L Fernando
- Department of Clinical Immunology and Allergy, Royal North Shore, Sydney, NSW, Australia.,Immunology Laboratory, New South Wales Health Pathology, Royal North Shore, Sydney, NSW, Australia.,University of Sydney, Sydney, NSW, Australia
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20
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Newkirk RE, Fomin DA, Braden MM. Erythema Multiforme Versus Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis: Subtle Difference in Presentation, Major Difference in Management. Mil Med 2020; 185:e1847-e1850. [PMID: 32373930 DOI: 10.1093/milmed/usaa029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 01/21/2020] [Accepted: 01/30/2020] [Indexed: 12/16/2022] Open
Abstract
Erythema multiforme and Stevens-Johnson syndrome/toxic epidermal necrolysis are immune-mediated epidermal conditions with variable clinical presentations. Although their clinical presentations often overlap, they have distinct etiologies and potential outcomes, which necessitate specific management strategies. This case is presented to highlight the subtle differences and review management given that Stevens-Johnson syndrome/toxic epidermal necrolysis can rapidly become life-threatening. The need for astute diagnostic work-up and accuracy is magnified in the military setting given operations in austere environments and availability of medical and medical evacuation resources. Herein, we present a less common case of bullous erythema-multiforme, the diagnostic approach, and clinical differential with special attention to the importance of the military physician.
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Affiliation(s)
- Russell E Newkirk
- School of Medicine, Uniformed Services University, 4301 Jones Bridge Road, Bethesda MD 20814
| | - Daren A Fomin
- Department of Dermatology, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda MD 20889
| | - Mary M Braden
- Department of Dermatology, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda MD 20889
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21
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Grünwald P, Mockenhaupt M, Panzer R, Emmert S. Erythema exsudativum multiforme, Stevens‐Johnson‐Syndrom/toxische epidermale Nekrolyse – Diagnostik und Therapie. J Dtsch Dermatol Ges 2020; 18:547-553. [PMID: 32519478 DOI: 10.1111/ddg.14118_g] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 01/02/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Pavel Grünwald
- Klinik und Poliklinik für Dermatologie und Venerologie, Universitätsmedizin Rostock
| | - Maja Mockenhaupt
- Dokumentationszentrum schwerer Hautreaktionen (dZh), Klinik für Dermatologie und Venerologie, Universitätsklinikum Freiburg
| | - Rüdiger Panzer
- Klinik und Poliklinik für Dermatologie und Venerologie, Universitätsmedizin Rostock
| | - Steffen Emmert
- Klinik und Poliklinik für Dermatologie und Venerologie, Universitätsmedizin Rostock
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22
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Grünwald P, Mockenhaupt M, Panzer R, Emmert S. Erythema multiforme, Stevens-Johnson syndrome/toxic epidermal necrolysis - diagnosis and treatment. J Dtsch Dermatol Ges 2020; 18:547-553. [PMID: 32469468 DOI: 10.1111/ddg.14118] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 01/02/2020] [Indexed: 12/31/2022]
Abstract
Prior to the first international consensus classification published in 1993, the clinical distinction between erythema multiforme (EM), Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) had been subject to uncertainty and controversy for more than a century. Based on this classification, the three conditions are defined by the morphology of the individual lesions and their pattern of distribution. Etiopathogenetically, the majority of EM cases is caused by infections (primarily herpes simplex virus and Mycoplasma pneumoniae), whereas SJS/TEN are predominantly triggered by drugs. The SCORTEN (score of toxic epidermal necrolysis) can and should be used to assess disease prognosis in patients with SJS/TEN. While supportive treatment is generally considered sufficient for EM, there is still uncertainty as to the type of systemic therapy required for SJS/TEN. Given the lack of high-quality therapeutic trials and (in some cases) conflicting results, it is currently impossible to issue definitive recommendations for any given immunomodulatory therapy. While there is always a trade-off between rapid onset of treatment-induced immunosuppression and an uptick in infection risk, there has been increasing evidence that cyclosporine in particular may be able to halt disease progression (i.e. skin detachment) and lower mortality rates. Assistance in diagnosis and management of the aforementioned conditions may be obtained from the Center for the Documentation of Severe Skin Reactions (dZh) at the Department of Dermatology, University Medical Center, Freiburg, Germany.
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Affiliation(s)
- Pavel Grünwald
- Department of Dermatology and Venereology, University Medical Center, Rostock, Germany
| | - Maja Mockenhaupt
- Center for the Documentation of Severe Skin Reactions (dZh), Department of Dermatology and Venereology, University Medical Center, Freiburg, Germany
| | - Rüdiger Panzer
- Department of Dermatology and Venereology, University Medical Center, Rostock, Germany
| | - Steffen Emmert
- Department of Dermatology and Venereology, University Medical Center, Rostock, Germany
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23
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Kaide CG, San Miguel CE. Stevens Johnson Syndrome – “Steven Who? And Why I Should Care About His Johnson?”. CASE STUDIES IN EMERGENCY MEDICINE 2020. [PMCID: PMC7122494 DOI: 10.1007/978-3-030-22445-5_55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Diagnosing rashes in the emergency department can be challenging. If the rash is extensive and targetoid, include Stevens-Johnson Syndrome (SJS) on your differential and be sure to obtain a thorough history to identify possible offending agents. Additionally, prioritize supportive care and obtaining a dermatology/burn consult to coordinate appropriate care.
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Affiliation(s)
- Colin G. Kaide
- Wexner Medical Center, Ohio State University, Columbus, OH USA
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24
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Petti S, Lodi G. The controversial natural history of oral herpes simplex virus type 1 infection. Oral Dis 2019; 25:1850-1865. [PMID: 31733122 DOI: 10.1111/odi.13234] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 10/29/2019] [Accepted: 11/10/2019] [Indexed: 02/06/2023]
Abstract
The natural history of oral herpes simplex virus type 1 (HSV-1) infection in the immunocompetent host is complex and rich in controversial phenomena, namely the role of unapparent transmission in primary infection acquisition, the high frequency of asymptomatic primary and recurrent infections, the lack of immunogenicity of HSV-1 internalized in the soma (cell body) of the sensory neurons of the trigeminal ganglion, the lytic activity of HSV-1 in the soma of neurons that is inhibited in the sensory neurons of the trigeminal ganglion and often uncontrolled in the other neurons, the role of keratin in promoting the development of recurrence episodes in immunocompetent hosts, the virus-host Nash equilibrium, the paradoxical HSV-1-seronegative individuals who shed HSV-1 through saliva, the limited efficacy of anti-HSV vaccines, and why the oral route of infection is the least likely to produce severe complications. The natural history of oral HSV-1 infection is also a history of symbiosis between humans and virus that may switch from mutualism to parasitism and vice versa. This balance is typical of microorganisms that are highly coevolved with humans, and its knowledge is essential to oral healthcare providers to perform adequate diagnosis and provide proper individual-based HSV-1 infection therapy.
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Affiliation(s)
- Stefano Petti
- Department of Public Health and Infectious Diseases, Sapienza University, Rome, Italy
| | - Giovanni Lodi
- Department of Biomedical, Surgical, and Dental Sciences, University of Milan, Milan, Italy
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25
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Mocanu A, Ivanov A, Alecsa M, Lupu VV, Lupu A, Starcea IM, Miron OT, Gavrilovici C, Miron IC. Uncommon erythema multiforme in small children: experience of a single Romanian pediatric unit: Two case reports. Medicine (Baltimore) 2019; 98:e17895. [PMID: 31725635 PMCID: PMC6867757 DOI: 10.1097/md.0000000000017895] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 09/24/2019] [Accepted: 10/09/2019] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Erythema multiforme (EM) is an immune-mediated disease with mucocutaneous localization and plurietiologic determinism. The term "multiforme" refers to the variety of aspects that the lesions can take from patient to patient and during evolution in a single patient. PATIENT CONCERNS We have selected 2 cases of small children diagnosed with different etiology of EM to illustrate the importance of a correct and fast diagnosis. Case 1 involves a 2-year-old girl from a rural area who presented with fever and pruritic erythematous papular eruption. The onset of the symptoms was 3 days before presentation with fever and ulcerative lesions on the oral and labial mucosa, followed by the appearance of erythematous macular lesions, with progressive confluence to intense pruritic patches. The 2nd involves a 2-year-old boy with fever, loss of appetite, productive cough, and petechiae. He had corticosensible immune thrombocytopenia from the age of 6 months, with many recurrences. The patient received treatment with ampicillin/sulbactam and symptomatics for an erythemato-pultaceous angina. During the 2nd day of treatment the patient developed an erythematous macular eruption on the face, scalp, trunk, and limbs, with bullae formation. DIAGNOSES The 1st patient was diagnosed based on biologic findings: positive inflammatory syndrome, elevated level of anti-Mycoplasma pneumoniae immunoglobulin M antibodies and immunoglobulin E. Histopathologic examination described papillary dermal edema, inflammatory infiltrate, and lymphocyte exocytosis. In the 2nd case, the hemoleucogram identified 12,000/mm platelets and the medulogram aspect was normal. Serology for Epstein-Barr virus was negative. The diagnosis was EM secondary to M pneumoniae infection in case 1 and secondary to administration of ampicillin/sulbactam in case 2. INTERVENTIONS In both cases, etiopathogenic treatment consisting of steroidal antiinflammatory drugs, antihistamines was administered. Because of specific etiology, the 1st case received antibiotics. OUTCOMES The evolution was favorable in 10 to 14 days; the patients were discharged after etiopathogenic treatment consisting of steroidal antiinflammatory drugs, antihistamines, and/or antibiotics. LESSONS Performing a detailed clinical examination, medical history of drug use, infection or general diseases can establish a good diagnosis of EM. Histopathologic examination can help. The treatment is etiologic, pathogenic, and symptomatic. EM usually has a self-limited evolution.
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Affiliation(s)
- Adriana Mocanu
- Department of Pediatrics, University of Medicine and Pharmacy “Grigore T. Popa”
- IVth Pediatric Department
| | - Anca Ivanov
- Department of Pediatrics, University of Medicine and Pharmacy “Grigore T. Popa”
- IVth Pediatric Department
| | - Mirabela Alecsa
- Department of Pediatrics, University of Medicine and Pharmacy “Grigore T. Popa”
- IVth Pediatric Department
| | - Vasile Valeriu Lupu
- Department of Pediatrics, University of Medicine and Pharmacy “Grigore T. Popa”
- IVth Pediatric Department
| | - Ancuta Lupu
- Department of Pediatrics, University of Medicine and Pharmacy “Grigore T. Popa”
- Vth Pediatric Department, Sf. Maria Emergency Hospital for Children, Iasi, Romania
| | - Iuliana Magdalena Starcea
- Department of Pediatrics, University of Medicine and Pharmacy “Grigore T. Popa”
- IVth Pediatric Department
| | - Oana Tatiana Miron
- Department of Pediatrics, University of Medicine and Pharmacy “Grigore T. Popa”
| | - Cristina Gavrilovici
- Department of Pediatrics, University of Medicine and Pharmacy “Grigore T. Popa”
- IVth Pediatric Department
| | - Ingrith Crenguta Miron
- Department of Pediatrics, University of Medicine and Pharmacy “Grigore T. Popa”
- IVth Pediatric Department
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Abstract
Mucocutaneous diseases affecting the oral cavity are predominantly immune mediated or inflammatory. Three of the most common and clinically significant conditions are reviewed in this article: lichen planus, pemphigus vulgaris, and mucous membrane pemphigoid. Because oral manifestations may be the first or only manifestation of mucocutaneous diseases, oral health professionals play a critical role in the early diagnosis and multidisciplinary management of these conditions.
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27
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Zhong CS, Richardson ET, Laga Canales AC, Nambudiri VE. Atypical cutaneous targetoid lesions after bone marrow transplant. BMJ Case Rep 2019; 12:12/8/e230142. [PMID: 31409617 DOI: 10.1136/bcr-2019-230142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 69-year-old man with esophageal EBV-positive diffuse large B cell lymphoma status post allogeneic bone marrow transplant (BMT) five months prior presented to his oncologist with three days of maculopapular rash that was initially diagnosed as grade 1 graft-versus-host disease and started on oral prednisone. However, due to worsening of the rash, the patient presented to dermatology clinic, where skin biopsy revealed a diagnosis of erythema multiforme (EM). The patient improved with the use of topical steroids. This case highlights the atypical morphology of post-BMT EM and the potential causes for this atypical appearance.
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Affiliation(s)
- Connie S Zhong
- Harvard Medical School, Boston, Massachusetts, USA.,Dermatology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Edward T Richardson
- Harvard Medical School, Boston, Massachusetts, USA.,Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Alvaro C Laga Canales
- Harvard Medical School, Boston, Massachusetts, USA.,Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Vinod E Nambudiri
- Harvard Medical School, Boston, Massachusetts, USA.,Dermatology, Brigham and Women's Hospital, Boston, Massachusetts, USA
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28
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Triggers, clinical manifestations, and management of pediatric erythema multiforme: A systematic review. J Am Acad Dermatol 2019; 81:813-822. [PMID: 31331726 DOI: 10.1016/j.jaad.2019.02.057] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 02/20/2019] [Accepted: 02/24/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Erythema multiforme (EM) is an acute inflammatory mucocutaneous condition. EM is rarely described in children and infants. OBJECTIVE To investigate the triggers, clinical manifestations, and treatment of pediatric EM. METHODS Systematic literature review of pediatric EM. RESULTS After full-text article review, we included 113 articles, representing 580 patients. The mean age was 5.6 years, ranging 0.1-17 years. Infectious agents were the main triggers: herpes simplex virus (HSV) in 104 patients (17.9%) and Mycoplasma pneumoniae in 91 patients (15.7%). In total, 140 cases (24.1%) were drug-related and 89 cases (15.3%) had other triggers, such as vaccines (19 patients, 3.2%). In total, 229 patients had EM major (39.5%). Treatment was supportive care only (180 patients, 31.1%), systemic corticosteroids (115 patients, 19.8%), antivirals (85 patients, 14.6%), and antibiotics (66 patients, 11.3%), mostly macrolides (45 patients, 7.7%). Long-term sequelae were rare (1.3%). Pediatric EM was reported in 19 infants (3.2%). The main trigger was vaccination (9 patients). Infantile EM was EM major in 2 cases and EM minor in 17. Infants were less prone to develop EM major than older children (P < .01). Pediatric EM was recurrent in 83 cases (14.3%), which was triggered by HSV in 36 patients (61%). Recurrence affected older children. LIMITATIONS Potential confusion between Steven Johnson syndrome and EM major in addition to publication bias. CONCLUSION Pediatric EM is a rare disease, mainly triggered by infections. This condition can affect all mucosal surfaces, most commonly the oral mucosae. The diagnosis is clinical, and management relies on supportive care. Vaccines are a particular trigger in infants. Recurrent cases are most commonly linked to HSV. Dermatologists and pediatricians should be aware of this potentially recurrent and severe condition.
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29
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Grassi S, Bossi G, Croci GA, Brazzelli V. Recurrent erythema multiforme major in an 8-year-old patient with recurrence of herpetic gingivostomatitis and HLA-B*5801 haplotype: A causal or casual relationship? JAAD Case Rep 2019; 5:617-620. [PMID: 31341940 PMCID: PMC6629837 DOI: 10.1016/j.jdcr.2019.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Sara Grassi
- Department of Internal Medicine and Medical Specialties, "La Sapienza" University of Rome, Rome, Italy
| | - Grazia Bossi
- Department of Pediatrics, Fondazione Policlinico San Matteo IRCCS, University of Pavia, Pavia, Italy
| | - Giorgio A Croci
- Department of Pathology, Fondazione Policlinico San Matteo IRCCS, University of Pavia, Pavia, Italy
| | - Valeria Brazzelli
- Institute of Dermatology, Department of Clinical-Surgical, Diagnostic and Pediatric Science, Fondazione Policlinico San Matteo IRCCS, University of Pavia, Pavia, Italy
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30
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Grosber M. 38/w mit rezidivierenden Kokardenläsionen an den Händen. Hautarzt 2019; 70:61-63. [DOI: 10.1007/s00105-018-4329-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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31
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Yiu D, Ballabio M, Fornoni G, Maggi U. Unusual oral presentation of HSV-1 lesions in an adult liver transplant recipient. BMJ Case Rep 2019; 12:12/3/e227492. [PMID: 30852500 DOI: 10.1136/bcr-2018-227492] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Herpes Simplex Virus (HSV) hepatitis in liver transplant patients is a rarely reported infective complication of HSV with severe consequences, often leading to fulminant hepatitis if left untreated. The clinical signs are often atypical, leading to under-reporting in the literature and potential delays in treatment. Our case report describes such atypical mucocutaneous lesions in a liver transplant recipient. We highlight the need for further reports, especially those with images, in order to aid the diagnosis of HSV infection, and to allow prompt treatment to prevent complications such as HSV hepatitis.
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Affiliation(s)
- Daniel Yiu
- General Surgery, Frimley Health NHS Foundation Trust, Slough, UK
| | - Michele Ballabio
- UO Chirurgia Generale e Trapianti di Fegato, Ospedale Maggiore Policlinico, Milano, Italy
| | - Gianluca Fornoni
- UO Chirurgia Generale e Trapianti di Fegato, Ospedale Maggiore Policlinico, Milano, Italy
| | - Umberto Maggi
- HPB and Liver Transplant Unit, Osped Maggiore Policlin Milano, Milano, Italy
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32
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de Risi-Pugliese T, Sbidian E, Ingen-Housz-Oro S, Le Cleach L. Interventions for erythema multiforme: a systematic review. J Eur Acad Dermatol Venereol 2019; 33:842-849. [PMID: 30680804 DOI: 10.1111/jdv.15447] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 12/19/2018] [Indexed: 11/28/2022]
Abstract
Treatment of erythema multiforme (EM) is not codified. We performed a systematic review of the effect of any topical or systemic treatment on time to healing and frequency of episodes with acute and chronic forms of EM in adults. Four databases (MEDLINE, CENTRAL, EMBASE and LILACS) and other sources were searched for articles published up to 20 March 2018. Randomized control trials (RCTs), observational studies and case series (n ≥ 10) were considered. From 1558 references, we included one RCT and six case series. The RCT (n = 20) showed a significant difference in complete remission of EM with continuous acyclovir vs. placebo over 6 months. One case series found a mean reduction in flare duration with thalidomide for recurrent EM (5.1 vs. 16.2 days; n = 20). Adverse events were poorly or not reported in included studies. Quality of life was never assessed. One limitation of our study is that we excluded the cases of isolated mucosal EM in order to prevent inclusion of Stevens-Johnson syndrome cases. In conclusion, there is low-level evidence for continuous acyclovir treatment for recurrent EM (one RCT). Evidence for other treatments is only based on retrospective case series. Results for thalidomide, in particular, encourage further research. Data concerning safety are insufficient. PROSPERO registration no. CRD42016053175.
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Affiliation(s)
- T de Risi-Pugliese
- Service de Dermatologie, AP-HP, Hôpital Henri Mondor, Créteil, France.,Service de Dermatologie et Allergologie, AP-HP, Hôpital Tenon, Paris, France
| | - E Sbidian
- Service de Dermatologie, AP-HP, Hôpital Henri Mondor, Créteil, France.,EA 7379 EpiDermE (Epidemiology in Dermatology and Evaluation of Therapeutics), Créteil, France.,INSERM CIC 1430, Paris-Est Creteil University, Creteil, France
| | - S Ingen-Housz-Oro
- Service de Dermatologie, AP-HP, Hôpital Henri Mondor, Créteil, France.,EA 7379 EpiDermE (Epidemiology in Dermatology and Evaluation of Therapeutics), Créteil, France
| | - L Le Cleach
- Service de Dermatologie, AP-HP, Hôpital Henri Mondor, Créteil, France.,EA 7379 EpiDermE (Epidemiology in Dermatology and Evaluation of Therapeutics), Créteil, France
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Paulino L, Hamblin DJ, Osondu N, Amini R. Variants of Erythema Multiforme: A Case Report and Literature Review. Cureus 2018; 10:e3459. [PMID: 30564538 PMCID: PMC6298627 DOI: 10.7759/cureus.3459] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Erythema multiforme is an acute skin condition characterized by targetoid lesions and occurs most frequently in young adults, particularly males. There are two variants of this condition, one with mucosal involvement, termed erythema multiforme major, and one without mucosal involvement, known as erythema multiforme minor. Due to the similarities in clinical and histological findings, it was previously believed that erythema multiforme major was indistinguishable from Steven-Johnson syndrome (SJS). However, evidence suggests these are two distinct diseases with a different etiology. It is important for clinicians to readily identify the difference between erythema multiforme from SJS, as the prognosis and mortality rate vary significantly between the two disorders.
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Affiliation(s)
- Luis Paulino
- Medical Education and Simulation, University of Arizona College of Medicine, Tucson, USA
| | - David J Hamblin
- Medical Education and Simulation, University of Arizona College of Medicine, Tucson, USA
| | - Ngozi Osondu
- Infectious Diseases, University of Arizona College of Medicine, Tucson, USA
| | - Richard Amini
- Emergency Medicine, University of Arizona College of Medicine, Tucson, USA
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Liu RF, Chen CB, Hui RC, Kuan YZ, Chung WH. The effect of levamisole in the treatment of recalcitrant recurrent erythema multiforme major: An observational study. J Dermatol Sci 2018; 92:38-44. [DOI: 10.1016/j.jdermsci.2018.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 07/25/2018] [Accepted: 08/05/2018] [Indexed: 01/12/2023]
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Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are considered a delayed-type hypersensitivity reaction to drugs. They represent true medical emergencies and an early recognition and appropriate management is decisive for the survival. SJS/TEN manifest with an "influenza-like" prodromal phase (malaise, fever), followed by painful cutaneous and mucous membrane (ocular, oral, and genital) lesions, and other systemic symptoms. The difference between SJS, SJS/TEN overlap, and TEN is defined by the degree of skin detachment: SJS is defined as skin involvement of < 10%, TEN is defined as skin involvement of > 30%, and SJS/TEN overlap as 10-30% skin involvement. The diagnosis of different degrees of epidermal necrolysis is based on the clinical assessment in conjunction with the corresponding histopathology. The mortality rates for SJS and TEN have decreased in the last decades. Today, the severity-of-illness score for toxic epidermal necrolysis (SCORTEN) is available for SJS/TEN severity assessment. Drugs with a high risk of causing SJS/TEN are anti-infective sulfonamides, anti-epileptic drugs, non-steroidal anti-inflammatory drugs of the oxicam type, allopurinol, nevirapine, and chlormezanone. Besides conventional drugs, herbal remedies and new biologicals should be considered as causative agents. The increased risk of hypersensitivity reactions to certain drugs may be linked to specific HLA antigens. Our understanding of the pathogenesis of SJS/TEN has improved: drug-specific T cell-mediated cytotoxicity, genetic linkage with HLA- and non-HLA-genes, TCR restriction, and cytotoxicity mechanisms were clarified. However, many factors contributing to epidermal necrolysis still have to be identified, especially in virus-induced and autoimmune forms of epidermal necrolysis not related to drugs. In SJS/TEN, the most common complications are ocular, cutaneous, or renal. Nasopharyngeal, esophageal, and genital mucosal involvement with blisters, erosions as well as secondary development of strictures also play a role. However, in the acute phase, septicemia is a leading cause of morbidity and fatality. Pulmonary and hepatic involvement is frequent. The acute management of SJS/TEN requires a multidisciplinary approach. Immediate withdrawal of potentially causative drugs is mandatory. Prompt referral to an appropriate medical center for specific supportive treatment is of utmost importance. The most frequently used treatments for SJS/TEN are systemic corticosteroids, immunoglobulins, and cyclosporine A.
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Lerch M, Mainetti C, Terziroli Beretta-Piccoli B, Harr T. Current Perspectives on Erythema Multiforme. Clin Rev Allergy Immunol 2018; 54:177-184. [PMID: 29352387 DOI: 10.1007/s12016-017-8667-7] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Recognition and timely adequate treatment of erythema multiforme remain a major challenge. In this review, current diagnostic guidelines, potential pitfalls, and modern/novel treatment options are summarized with the aim to help clinicians with diagnostic and therapeutic decision-making. The diagnosis of erythema multiforme, that has an acute, self-limiting course, is based on its typical clinical picture of targetoid erythematous lesions with predominant acral localization as well as histological findings. Clinically, erythema multiforme can be differentiated into isolated cutaneous and combined mucocutaneous forms. Atypical erythema multiforme manifestations include lichenoid or granulomatous lesions as well as lesional infiltrates of T cell lymphoma and histiocytes. Herpes simplex virus infection being the most common cause, other infectious agents like-especially in children-Mycoplasma pneumoniae, hepatitis C virus, Coxsackie virus, and Epstein Barr virus may also trigger erythema multiforme. The second most frequently identified cause of erythema multiforme is drugs. In different studies, e.g., allopurinol, phenobarbital, phenytoin, valproic acid, antibacterial sulfonamides, penicillins, erythromycin, nitrofurantoin, tetracyclines, chlormezanone, acetylsalicylic acid, statins, as well as different TNF-α inhibitors such as adalimumab, infliximab, and etanercept were reported as possible implicated drugs. Recently, cases of erythema multiforme associated with vaccination, immunotherapy for melanoma, and even with topical drugs like imiquimod have been described. In patients with recurrent herpes simplex virus-associated erythema multiforme, the topical prophylactic treatment with acyclovir does not seem to prevent further episodes of erythema multiforme. In case of resistance to one virostatic drug, the switch to an alternative drug, and in patients non-responsive to virostatic agents, the use of dapsone as well as new treatment options, e.g., JAK-inhibitors or apremilast, might be considered.
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Affiliation(s)
- Marianne Lerch
- Allergy/Dermatology Unit, Department of Internal Medicine, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Carlo Mainetti
- Department of Dermatology, Bellinzona Regional Hospital, Bellinzona, Switzerland
| | | | - Thomas Harr
- Unité d'allergologie, Service d'immunologie et d'allergologie, Hôpitaux Universitaires de Genève HUG, Rue Micheli-du-Crest 24, CH-1211, Genève, Switzerland.
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Maderal AD, Lee Salisbury P, Jorizzo JL. Desquamative gingivitis. J Am Acad Dermatol 2018; 78:839-848. [DOI: 10.1016/j.jaad.2017.05.056] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 05/30/2017] [Accepted: 05/31/2017] [Indexed: 12/13/2022]
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Heinze A, Tollefson M, Holland KE, Chiu YE. Characteristics of pediatric recurrent erythema multiforme. Pediatr Dermatol 2018; 35:97-103. [PMID: 29231254 DOI: 10.1111/pde.13357] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Erythema multiforme (EM) is an acute condition characterized by distinctive target lesions of the skin often accompanied by mucosal ulcers. A subset of individuals experience frequent episodes of recurrent EM, which is rare and poorly understood, especially in children. OBJECTIVE To characterize clinical features, laboratory findings, and treatment responses of pediatric recurrent EM. METHODS A retrospective chart review was conducted at the Children's Hospital of Wisconsin in Milwaukee, Wisconsin (2000-2015) and the Mayo Clinic in Rochester, Minnesota (1990-2015). Inclusion criterion was a diagnosis before age 18 years with recurrent EM, defined as a symmetrically distributed, fixed eruption, including target lesions, with or without mucous membrane involvement, occurring on at least three occasions. A literature review was conducted to include individuals who met the inclusion criterion. RESULTS Twenty-six patients were included, of whom 16 (62%) were male. The median age of onset was 9.1 years (range 0-15.7 years). Nine patients (35%) required hospitalization. Herpes simplex virus testing was positive in 9 of 17 (65%) patients. Remission was achieved in 5 of 16 (31%) patients while taking suppressive antivirals. Eight patients received continuous anti-inflammatory treatment, two (25%) of whom experienced remission. CONCLUSION This study of pediatric recurrent EM found a greater male predominance, more hospitalizations, fewer cases caused by herpes simplex virus, and a lower response to immunosuppression in children than in the general population.
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Affiliation(s)
- Adam Heinze
- Medical College of Wisconsin, Milwaukee, WI, USA
| | - Megha Tollefson
- Section of Pediatric Dermatology, Departments of Dermatology and Pediatrics, Mayo Clinic, Rochester, MN, USA
| | - Kristen E Holland
- Section of Pediatric Dermatology, Departments of Dermatology and Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Yvonne E Chiu
- Section of Pediatric Dermatology, Departments of Dermatology and Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
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Ikeda K. Drug-Induced Oral Complications. Atlas Oral Maxillofac Surg Clin North Am 2017; 25:127-132. [PMID: 28778302 DOI: 10.1016/j.cxom.2017.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Kentaro Ikeda
- Department of Diagnostics and Biological Sciences, University of Colorado School of Dental Medicine, 13065 East 17th Avenue, Mail Stop F844, Aurora, CO 80045, USA; Department of Family Medicine, University of Colorado School of Medicine, 12631 East 17th Avenue, Aurora, CO 80045, USA.
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Abstract
OBJECTIVES Erythema multiforme (EM) is characterized by symmetrical acrally distributed target lesions; however, other conditions can mimic the clinical features of EM. Although it is typically self-limiting, alternative diagnoses may be life-threatening and require immediate identification and treatment. This study aimed to investigate the clinical spectrum and accuracy of diagnosis of pediatric EM in the emergency department (ED). METHODS A retrospective, descriptive study of all pediatric patients with an ED information system diagnosis of EM at 2 EDs in Southeast Queensland between January 2010 and July 2013. Cases were evaluated using previously established EM classification criteria. RESULTS Seventy patients (34 males and 36 females) with a diagnosis of EM were identified. From 57 cases where a diagnosis could be established, 9 cases fulfilled the classification criteria for EM. No patients had mucosal involvement, and therefore, all 9 cases were classified as EM minor, with the majority (89%) attributed to viral infection. Of the 48 cases that did not fit the criteria, the most common condition misdiagnosed as EM was urticaria multiforme (n = 20). CONCLUSIONS In the ED setting, EM in children is frequently misdiagnosed. Greater awareness of diagnostic factors for EM may improve diagnostic accuracy. Teledermatology and incentives to include clinical pictures in the (electronic) medical record may be useful adjuncts for patients with suspected EM and other dermatological conditions.
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Grunnet KM, Powell KS, Miller IA, Davis LS. Autoimmune progesterone dermatitis manifesting as mucosal erythema multiforme in the setting of HIV infection. JAAD Case Rep 2016; 3:22-24. [PMID: 28050592 PMCID: PMC5192350 DOI: 10.1016/j.jdcr.2016.10.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Kerrie M Grunnet
- Medical College of Georgia at Augusta University, Augusta, Georgia
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Idiopathic erythema multiforme: Evidence of underlying Janus kinase-signal transducer and activator of transcription activation and successful treatment with tofacitinib. JAAD Case Rep 2016; 2:502-504. [PMID: 28004029 PMCID: PMC5161778 DOI: 10.1016/j.jdcr.2016.10.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Konvinse KC, Phillips EJ, White KD, Trubiano JA. Old dog begging for new tricks: current practices and future directions in the diagnosis of delayed antimicrobial hypersensitivity. Curr Opin Infect Dis 2016; 29:561-576. [PMID: 27753687 PMCID: PMC5113146 DOI: 10.1097/qco.0000000000000323] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Antimicrobials are a leading cause of severe T cell-mediated adverse drug reactions (ADRs). The purpose of this review is to address the current understanding of antimicrobial cross-reactivity and the ready availability of and evidence for in-vitro, in-vivo, and ex-vivo diagnostics for T cell-mediated ADRs. RECENT FINDINGS Recent literature has evaluated the efficacy of traditional antibiotic allergy management, including patch testing, skin prick testing, intradermal testing, and oral challenge. Although patch and intradermal testing are specific for the diagnosis of immune-mediated ADRs, they suffer from drug-specific limitations in sensitivity. The use of ex-vivo diagnostics, especially enzyme-linked immunospot, has been highlighted as a promising new approach to assigning causality. Knowledge of true rates of antimicrobial cross-reactivity aids empirical antibiotic choice in the setting of previous immune-mediated ADRs. SUMMARY In an era of increasing antimicrobial resistance and use of broad-spectrum antimicrobial therapy, ensuring patients are assigned the correct 'allergy label' is essential. Re-exposure to implicated antimicrobials, especially in the setting of severe adverse cutaneous reaction, is associated with significant morbidity and mortality. The process through which an antibiotic label gets assigned, acted on and maintained is still imprecise. Predicting T cell-mediated ADRs via personalized approaches, including human leukocyte antigen-typing, may pave future pathways to safer antimicrobial prescribing guidelines.
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Affiliation(s)
- Katherine C Konvinse
- aDepartment of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA bInstitute for Immunology and Infectious Diseases, Murdoch University, Western Australia, Australia cDepartment of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA dDepartment of Medicine, Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA eDepartment of Infectious Diseases, Austin Hospital, Victoria, Australia fDepartment of Infectious Diseases, Alfred Hospital, Victoria, Australia gDepartment of Infectious Diseases, Peter MacCallum Cancer Centre, Victoria, Australia hDepartment of Medicine, University of Melbourne, Victoria, Australia
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Oak ASW, Seminario-Vidal L, Sami N. Treatment of antiviral-resistant recurrent erythema multiforme with dapsone. Dermatol Ther 2016; 30. [PMID: 27860166 DOI: 10.1111/dth.12449] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 09/18/2016] [Accepted: 10/21/2016] [Indexed: 11/28/2022]
Abstract
Recurrent erythema multiforme (REM) is a chronic disease characterized by frequent episodes of target cutaneous lesions in an acral distribution. Conventional treatment includes systemic corticosteroids and antiviral therapy. The aim of this study was to evaluate dapsone as a potential steroid sparing-agent for the treatment of REM after a failed trial of at least one antiviral therapy (acyclovir, famciclovir, or valacyclovir). A retrospective chart review was conducted on thirteen patients with a diagnosis of REM who underwent treatment with dapsone after failing at least one antiviral therapy. Out of 13 patients, 6 showed complete response (CR) and 5 showed partial response (PR). The underlying cause was identified in 5 patients with all showing at least PR. Adverse effects, observed in 4 patients, included fatigue, macrocytic anemia, anxiety, insomnia and involuntary movements, and drug-induced lupus erythematosus. A continuous course of dapsone, titrated up from 25 mg/day to a dose at which clinical improvement is seen with acceptable patient tolerance, is a viable steroid sparing-agent for REM treatment after a failed trial of antiviral therapy.
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Affiliation(s)
- Allen S W Oak
- Department of Dermatology, University of Alabama at Birmingham, Birmingham, AL
| | | | - Naveed Sami
- Department of Dermatology, University of Alabama at Birmingham, Birmingham, AL
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Yacoub MR, Berti A, Campochiaro C, Tombetti E, Ramirez GA, Nico A, Di Leo E, Fantini P, Sabbadini MG, Nettis E, Colombo G. Drug induced exfoliative dermatitis: state of the art. Clin Mol Allergy 2016; 14:9. [PMID: 27551239 PMCID: PMC4993006 DOI: 10.1186/s12948-016-0045-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Accepted: 07/27/2016] [Indexed: 01/15/2023] Open
Abstract
Drug induced exfoliative dermatitis (ED) are a group of rare and severe drug hypersensitivity reactions (DHR) involving skin and usually occurring from days to several weeks after drug exposure. Erythema multiforme (EM), Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are the main clinical presentations of drug induced ED. Overall, T cells are the central player of these immune-mediated drug reactions. Here we provide a systematic review on frequency, risk factors, pathogenesis, clinical features and management of patients with drug induced ED.
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Affiliation(s)
- Mona-Rita Yacoub
- Department of Allergy and Clinical Immunology, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy ; Vita-Salute San Raffaele University, Milan, Italy
| | - Alvise Berti
- Vita-Salute San Raffaele University, Milan, Italy
| | | | | | | | - Andrea Nico
- Section of Allergy and Clinical Immunology, Dept. of Internal Medicine, University of Bari, Bari, Italy
| | - Elisabetta Di Leo
- Section of Allergy and Clinical Immunology, Dept. of Internal Medicine, University of Bari, Bari, Italy
| | - Paola Fantini
- Section of Allergy and Clinical Immunology, Dept. of Internal Medicine, University of Bari, Bari, Italy
| | - Maria Grazia Sabbadini
- Department of Allergy and Clinical Immunology, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy ; Vita-Salute San Raffaele University, Milan, Italy
| | - Eustachio Nettis
- Section of Allergy and Clinical Immunology, Dept. of Internal Medicine, University of Bari, Bari, Italy
| | - Giselda Colombo
- Department of Allergy and Clinical Immunology, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy ; Vita-Salute San Raffaele University, Milan, Italy
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Goodale EC, White SD, Outerbridge CA, Everett AD, Affolter VK. A retrospective review of hyperaesthetic leucotrichia in horses in the USA. Vet Dermatol 2016; 27:294-e72. [PMID: 27374470 DOI: 10.1111/vde.12327] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Hyperaesthetic leucotrichia (HL) rarely affects horses and causes painful lesions on the dorsum that result in leucotrichia. This may be a variant of erythema multiforme (EM), but there are no studies investigating this condition. OBJECTIVES Describe the clinical and histological features of HL and compare them to the histological features of EM. METHODS A retrospective review of medical records from 1985 to 2015 identified 15 horses with HL. Thirteen biopsies of HL and five of EM were evaluated and compared. RESULTS Arabian horses and their crosses (χ(2) (1) = 8.56, P < 0.01) and American paint horses (χ(2) (1) = 6.64, P < 0.05) were over represented. The onset of clinical signs was between April and September (14 of 15). The most common clinical signs were pain (15 of 15), leucotrichia (11 of 15), crusting (10 of 15) and alopecia (8 of 15) limited to darkly pigmented skin. The lesions recurred seasonally in 6 of 12 horses and unpredictably in 1 of 12 horse. The most common histological features were the presence of large stellate cells (13 of 13) and oedema (12 of 13) in the superficial dermis, perivascular to diffuse lymphocytic inflammation (13 of 13), pigmentary incontinence (12 of 13), apoptotic keratinocytes (9 of 13) and vesicle formation (8 of 13). Horses with EM (n = 5) had significantly more acanthosis (z = -2.40, P < 0.02) and lymphocytic exocytosis (z = -3.1, P < 0.004), satellitosis (Fisher's exact P = 0.02) and inflammation (z = -2.91, P < 0.004). Horses with HL had significantly more pigmentary incontinence (z = 2.13, P < 0.04) and superficial dermal oedema (z = 2.56, P < 0.002). CONCLUSIONS HL affects primarily Arabian horses and American paint horses. It occurs mainly in summer and may recur. Histologically HL shares features with EM, but there are significant differences between them.
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Affiliation(s)
- Elizabeth C Goodale
- William R. Pritchard Veterinary Medical Teaching Hospital, School of Veterinary Medicine, University of California Davis, 1 Garrod Drive, Davis, CA, 95616, USA
| | - Stephen D White
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California Davis, 1 Garrod Drive, Davis, CA, 95616, USA
| | - Catherine A Outerbridge
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California Davis, 1 Garrod Drive, Davis, CA, 95616, USA
| | - Angela D Everett
- William R. Pritchard Veterinary Medical Teaching Hospital, School of Veterinary Medicine, University of California Davis, 1 Garrod Drive, Davis, CA, 95616, USA
| | - Verena K Affolter
- Department of Pathology, Microbiology & Immunology, School of Veterinary Medicine, University of California Davis, 1 Garrod Drive, Davis, CA, 95616, USA
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Celentano A, Tovaru S, Yap T, Adamo D, Aria M, Mignogna MD. Oral erythema multiforme: trends and clinical findings of a large retrospective European case series. Oral Surg Oral Med Oral Pathol Oral Radiol 2015; 120:707-16. [DOI: 10.1016/j.oooo.2015.08.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 08/08/2015] [Accepted: 08/13/2015] [Indexed: 12/24/2022]
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Hirsch G, Ingen-Housz-Oro S, Fite C, Valeyrie-Allanore L, Ortonne N, Buffard V, Verlinde-Carvalho M, Marinho E, Martinet J, Grootenboer-Mignot S, Descamps V, Wolkenstein P, Joly P, Chosidow O. Rituximab, a new treatment for difficult-to-treat chronic erythema multiforme major? Five cases. J Eur Acad Dermatol Venereol 2015; 30:1140-3. [PMID: 26369288 DOI: 10.1111/jdv.13313] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 06/24/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Erythema multiforme major (EMM) is an inflammatory disease affecting skin and mucosae, often triggered by infection with Herpes simplex virus. Some patients have a chronic disease associated with antidesmoplakin autoantibodies, but the pathophysiology remains to be elucidated. First-line treatment is antiviral therapy. With treatment failure or in patients without herpes-triggered disease, thalidomide is effective but has neurological side-effects. Alternatives (dapsone, immunosuppressant agents) are not codified. For many patients, systemic steroids use is chronic. The immunosuppressant drug rituximab (RTX) may be effective. OBJECTIVES We report five cases of severe chronic EMM treated with rituximab (RTX). METHODS Five patients with severe chronic EMM for 9-20 years received RTX after failure or side-effects of several treatments, especially antiviral therapy and thalidomide. All had chronic use of steroids. Four patients had antidesmoplakin autoantibodies. RESULTS Four patients experienced complete or quasi-complete remission of EMM with withdrawal of steroids and one patient partial remission, for 3-11 months. Disease relapsed in all patients, and three received a second cycle of RTX with shorter duration of efficacy. Two patients received a third cycle, one without efficacy. CONCLUSION The use of RTX for many autoimmune diseases, especially pemphigus, is increasing. Chronic EMM, especially EMM associated to antidesmoplakin autoantibodies, is an inflammatory disease in which the role of B cells is not well understood. However, we report a favourable benefit of RTX treatment for months in five patients with severe disease. RTX could be a therapeutic option in severe, difficult-to-treat EMM.
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Affiliation(s)
- G Hirsch
- Department of Dermatology, Assistance Publique-Hôpitaux de Paris, Henri Mondor Hospital, Créteil, France
| | - S Ingen-Housz-Oro
- Department of Dermatology, Assistance Publique-Hôpitaux de Paris, Henri Mondor Hospital, Créteil, France.,EA EpiDermE (Epidémiologie en Dermatologie et Evaluation des Thérapeutiques), UPEC, Créteil, France.,Referral center for auto-immune and toxic blistering diseases, Paris, Créteil, France
| | - C Fite
- Referral center for auto-immune and toxic blistering diseases, Paris, Créteil, France.,Department of Dermatology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France
| | - L Valeyrie-Allanore
- Department of Dermatology, Assistance Publique-Hôpitaux de Paris, Henri Mondor Hospital, Créteil, France.,EA EpiDermE (Epidémiologie en Dermatologie et Evaluation des Thérapeutiques), UPEC, Créteil, France.,Referral center for auto-immune and toxic blistering diseases, Paris, Créteil, France
| | - N Ortonne
- Department of Pathology, Assistance Publique-Hôpitaux de Paris, Henri Mondor Hospital, Créteil, France.,UPEC Université Paris-Est Créteil, Créteil, France
| | - V Buffard
- Department of Dermatology, Assistance Publique-Hôpitaux de Paris, Henri Mondor Hospital, Créteil, France
| | - M Verlinde-Carvalho
- Pharmacy, Assistance Publique-Hôpitaux de Paris, Henri Mondor Hospital, Créteil, France
| | - E Marinho
- Department of Pathology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France
| | - J Martinet
- Department of Immunology, Rouen University Hospital, Rouen, France.,Normandie University, IRIB, Rouen, France.,INSERM, U905, Rouen, France
| | - S Grootenboer-Mignot
- Referral center for auto-immune and toxic blistering diseases, Paris, Créteil, France.,Department of Immunology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France
| | - V Descamps
- Referral center for auto-immune and toxic blistering diseases, Paris, Créteil, France.,Department of Dermatology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France
| | - P Wolkenstein
- Department of Dermatology, Assistance Publique-Hôpitaux de Paris, Henri Mondor Hospital, Créteil, France.,EA EpiDermE (Epidémiologie en Dermatologie et Evaluation des Thérapeutiques), UPEC, Créteil, France.,Referral center for auto-immune and toxic blistering diseases, Paris, Créteil, France.,UPEC Université Paris-Est Créteil, Créteil, France
| | - P Joly
- Department of Dermatology, Charles Nicolle Hospital, Rouen, France
| | - O Chosidow
- Department of Dermatology, Assistance Publique-Hôpitaux de Paris, Henri Mondor Hospital, Créteil, France.,EA EpiDermE (Epidémiologie en Dermatologie et Evaluation des Thérapeutiques), UPEC, Créteil, France.,Referral center for auto-immune and toxic blistering diseases, Paris, Créteil, France.,UPEC Université Paris-Est Créteil, Créteil, France.,INSERM CIC 1430, Créteil, France
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49
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McKinley GF, Kaffenberger BH. Recurrent desquamative vulvovaginitis in a young woman. Int J Dermatol 2015; 55:21-3. [PMID: 26266812 DOI: 10.1111/ijd.12890] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 10/20/2014] [Accepted: 10/25/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Grant F McKinley
- Department of Dermatology, Ohio State University College of Medicine, Columbus, OH, USA
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50
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Abstract
Annular, or ring-like, skin lesions are a distinctive cutaneous morphology. Dermatologic diagnosis is based on morphology and distribution, and therefore the generation of a differential diagnosis based on these criteria can lead to proper identification of an eruption. For many dermatologic conditions, considering a differential that includes infection, immune phenomenon, neoplastic process, physical etiology, and idiopathic process will assure that one thinks broadly and is likely to reveal the best diagnosis. Several of these categories are covered in this review of annular eruptions in children.
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