Characteristics of the oral lesions in patients with cutaneous recurrent erythema multiforme

Erythema Multiforme in an HIV+ Patient on Highly Active Antiretroviral Therapy After Starting Paxlovid (Nirmatrelvir-Ritonivir)

In this report, we present a case of a woman currently on HIV antiretroviral therapy who presented with oral mucosal and cutaneous skin lesions with a target-like appearance following completion of a five-day course of Paxlovid™ for symptomatic COVID-19 infection. The patient was treated with intravenous steroids and oral antihistamines with mild improvement. However, she returned in one week with worsening skin lesions. The biopsy and infectious workup were non-contributory. It was determined that the patient had developed erythema multiforme (EM), secondary to Paxlovid™.

Differential Diagnosis of Lesions

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.

Recurrent erythema multiforme: A therapeutic proposal for a chronic disease

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.

Rashes and other hypersensitivity reactions associated with antiepileptic drugs: A review of current literature

This article provides an overview of the pathogenesis and risk factors associated with antiepileptic drug (AED) hypersensitivity reactions, provides prescribing guidelines that may minimize the risk of antiepileptic induced rashes, and discusses treatment options for rashes. Articles indexed in PubMed, Science Citation, and Google Scholar (January 1946-March 2019) were systematic searched using the following key terms: hypersensitivity, rash, antiepileptic, epilepsy, cross-sensitivity, desensitization, patch testing and supplemented with our clinical experiences. Additional references were identified from a review of literature citations. AEDs are associated with cutaneous adverse reactions. Aromatic AEDs and higher titration rates are associated with increased risk of hypersensitivity reaction. Patient characteristics, underlying health conditions, and genetic variations may increase the likelihood of a hypersensitivity reaction. Once a hypersensitivity reaction occurs, the likelihood of cross sensitivity to another AED increases, especially among other aromatic AEDs. Withdrawal of the causal agent and initiation of a lower risk agent usually leads to resolution of symptoms. Desensitization protocols may be an option for patients whose seizures only respond to the AED causing the rash.

Treatment of antiviral-resistant recurrent erythema multiforme with dapsone

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.

Treatment of a Pregnant Patient with Herpes Associated Erythema Multiforme (HAEM): A case report

Erythema Multiforme, (EM) is an uncommon, acute inflammatory disease of the skin and mucous membranes characterized by ulcerations caused by hypersensitivity to drugs, microbial agents or other allergens. An EM outbreak can result in more severe forms of EM involving the skin, and there are several types of EM manifestations. A hemorrhagic crust on the lip is a pathognomonic sign of this disease. Target lesions may or may not be present in EM cases. When target lesions are not present on the skin, it is very difficult to make a differential diagnosis of EM. Herpes associated erythema multiforme (HAEM) is an uncommon lesion caused by herpes simplex virus infection. A case of severe painful lesions in a 28-year-old pregnant patient with HAEM is presented here. HAEM is rarely found in pregnant women, and its clinical findings, diagnosis and treatment have not previously been reported.

Case Records of the Mass General Hospital. Case 7-2015: A 25-year-old man with oral ulcers, rash, and odynophagia

A 25-year-old man presented with oral ulcers and odynophagia. On examination, there were scattered pink papules and plaques on the trunk, thighs, and buttocks and multiple raised, erythematous nodules on both shins. A diagnostic procedure was performed.

Erythema multiforme: a review of epidemiology, pathogenesis, clinical features, and treatment

Erythema multiforme (EM) is an acute, immune-mediated disorder affecting the skin and/or mucous membranes, including the oral cavity. Target or iris lesions distributed symmetrically on the extremities and trunk characterize the condition. Infections are the most common cause of EM and the most frequently implicated infectious agent causing clinical disease is the herpes simplex virus. The diagnosis of EM is typically based on the patient's history and clinical findings. Management involves controlling the underlying infection or causative agent, symptom control, and adequate hydration. The epidemiology, pathogenesis, clinical features, diagnosis, and treatment of EM are reviewed in this article.

The last word on the so-called 'Rowell's syndrome'?

To date, 71 patients having the so-called 'Rowell's syndrome' (RS) have been reported in the literature. However, most of them did not show all the clinical and serological features first described by Rowell and co-workers in 1963. Moreover, since then, subacute cutaneous lupus erythematosus (SCLE) has been identified and the diagnostic criteria as well as the clinical features of erythema multiforme (EM) defined. Accordingly several authors have questioned the existence of RS over the past years. In the present paper, the main clinical, histopathological and immunopathological features of both SCLE and EM are described and all of the cases of RS reported in the literature are also reviewed in depth. A real association between discoid LE and EM was present only in a minority of cases and could be considered a mere coincidence. As for other associations, e.g. those between CLE and lichen planus or psoriasis, the coexistence of CLE and EM does not justify the framing of a separate syndrome as suggested by Rowell et al.

Recurrent erythema multiforme: clinical characteristics, etiologic associations, and treatment in a series of 48 patients at Mayo Clinic, 2000 to 2007

BACKGROUND

Recurrent erythema multiforme (EM) is a condition of substantial morbidity. Our efforts toward the etiologic attribution and treatment of recurrent EM have been less fruitful than those previously described.

OBJECTIVE

We sought to further characterize clinical characteristics, etiologic associations, and treatment of recurrent EM.

METHODS

We conducted a retrospective review of patients with recurrent EM seen between 2000 and 2007.

RESULTS

Of 48 patients (mean age at disease onset, 36.4 years), 28 (58%) were female (mean duration of recurrent EM, 6 years). Thirty (63%) patients had oral involvement. Herpes simplex virus caused recurrent EM in 11 (23%) patients, and the cause remained unknown in 28 (58%). In all, 37 (77%) patients received systemic corticosteroids, 33 (69%) received continuous antiviral treatment, and 23 (48%) used immunosuppressive or anti-inflammatory agents. Sixteen of 33 patients receiving continuous antiviral treatment had either partial or complete disease suppression. Patients had varied responses to immunosuppressants, with mycophenolate mofetil providing partial or complete response in 6 of 8 patients. Features of recalcitrant cases included clinicians' inability to identify a specific cause, lack of improvement with continuous antiviral therapy, severe oral involvement, extensive corticosteroid therapy, and immunosuppressive therapy (two or more agents).

LIMITATION

This study is retrospective.

CONCLUSIONS

More than half of patients in this study did not have an identifiable cause for recurrent EM, and herpes simplex virus was found less frequently than reported in previous studies. Response to systemic treatments, including continuous antivirals and immunosuppressants, was varied and often times suboptimal.

Oral mucosal diseases: Erythema multiforme

Erythema multiforme (EM) is a rare acute mucocutaneous condition caused by a hypersensitivity reaction with the appearance of cytotoxic T lymphocytes in the epithelium that induce apoptosis in keratinocytes, which leads to satellite cell necrosis. EM can be triggered by a range of factors, but the best documented association is with preceding infection with herpes simplex virus (HSV). Most other cases are initiated by drugs. EM has been classified into a number of variants, mainly minor and major forms, as it may involve the mouth alone, or present as a skin eruption with or without oral or other lesions of the mucous membrane. EM minor typically affects only one mucosa, and may be associated with symmetrical target skin lesions on the extremities. EM major typically involves two or more mucous membranes with more variable skin involvement. A severe variant of EM major is Stevens-Johnson syndrome, which typically extensively involves the skin. Both EM major and Stevens-Johnson syndrome can involve internal organs and produce systemic symptoms. Treatment of EM is controversial, as there is no reliable evidence. Precipitants should be avoided or treated and, in severe cases, corticosteroids may be needed. Toxic epidermal necrolysis may be similar to Stevens-Johnson syndrome, but many experts regard it as a discrete disease, and therefore it is not discussed here.

Erythema multiforme and related disorders

Erythema multiforme (EM) and related disorders comprise a group of mucocutaneous disorders characterized by variable degrees of mucosal and cutaneous blistering and ulceration that occasionally can give rise to systemic upset and possibly compromise life. The clinical classification of these disorders has often been variable, thus making definitive diagnosis sometimes difficult. Despite being often caused by, or at least associated with, infection or drug therapy, the pathogenic mechanisms of these disorders remain unclear, and as a consequence, there are no evidence-based, reliably effective therapies. The present article reviews aspects of EM and related disorders of relevance to oral medicine clinical practice and highlights the associated potential etiologic agents, pathogenic mechanisms and therapies.

Number IV Erythema multiforme

Erythema multiforme (EM) is an acute mucocutaneous hypersensitivity reaction characterised by a skin eruption, with or without oral or other mucous membrane lesions. Occasionally EM may involve the mouth alone. EM has been classified into a number of different variants based on the degree of mucosal involvement and the nature and distribution of the skin lesions. EM minor typically affects no more than one mucosa, is the most common form and may be associated with symmetrical target lesions on the extremities. EM major is more severe, typically involving two or more mucous membranes with more variable skin involvement - which is used to distinguish it from Stevens-Johnson syndrome (SJS), where there is extensive skin involvement and significant morbidity and a mortality rate of 5-15%. Both EM major and SJS can involve internal organs and typically are associated with systemic symptoms. Toxic epidermal necrolysis (TEN) may be a severe manifestation of EM, but some experts regard it as a discrete disease. EM can be triggered by a number of factors, but the best documented is preceding infection with herpes simplex virus (HSV), the lesions resulting from a cell mediated immune reaction triggered by HSV-DNA. SJS and TEN are usually initiated by drugs, and the tissue damage is mediated by soluble factors including Fas and FasL.

Factitial oral lesions in an autistic paediatric patient

Self Injurious Behaviour (SIB) is a deliberate harm to the body that may lead to factitial injuries. Its origin may be functional or biological and it has a higher prevalence in females and in psychologically impaired individuals. Seventy per cent of autistic patients have SIB. Seventy-five per cent of factitial injuries are located in the head and neck region. A paediatric case report concerning a 4-year-old autistic female is presented. Detailed medical history, physical examination, clinical intraoral and radiographic examination, incisional biopsy, neuropaediatrical, psychological and speech evaluation were undertaken. Diagnosis included hypochromic macrocytic anaemia, caries, coronal fracture, factitial ulcer, factitial periodontitis, self-extraction of primary teeth and permanent teeth buds, non-specific oral ulcer with inflammatory reaction, mild mental retardation, speech impairment, autistic syndrome and self injurious behaviour consisting of putting fingers and foreign objects in the gingiva, fingernail biting and hair pulling. Differential diagnosis included hystiocitosis X, prepuberal periodontitis and leukocyte adhesion deficiency. Dental preventive and restorative treatment was performed. Non-contingent reinforcement therapy was successfully used to diminish SIB. Treatment of factitial oral injuries must be interdisciplinary and requires cooperation of the patient, the parents, health care providers, and medical team.

New and emerging therapies for diseases of the oral cavity

It is obvious from the review of the literature that most treatments for oral diseases such as lichen planus, pemphigoid, and pemphigus are based on case reports, anecdotes, and small uncontrolled studies. Efforts must be made to perform more controlled studies to evaluate the efficacy of new treatments. Small numbers of patients at each site and multiple-drug therapy make this task difficult. Dermatologists should familiarize themselves with the newer immunosuppressive agents available. Use of these drugs requires knowledge of their pharmacokinetics and potential side effects, so that they may be used effectively and safely. Relatively low doses of azathioprine, cyclophosphamide, and cyclosporine should then be added to the dermatologist's armamentarium for the treatment of severe or recalcitrant diseases. Old drugs are resurfacing with new (but often off-label) uses as the underlying mechanisms of disease become understood. Thalidomide and mycophenolate mofetil are two examples of promising drugs for the future of dermatology.

The clinical spectrum of desquamative gingivitis

Desquamative gingivitis is a fairly common complaint. Typically seen in females who are middle-aged or older, it is predominantly a manifestation of a range of vesiculobullous disorders. The main complaint is of persistent soreness of the gingiva. Most cases are related to lichen planus or pemphigoid, but it is also important to exclude pemphigus, dermatitis herpetiformis, linear IgA disease, chronic ulcerative stomatitis, and other conditions. Biopsy is invariably required to confirm the diagnosis after a full history, general, and oral examination. Apart from improving the oral hygiene, immunosuppressive therapy is typically required to control the condition.

Target lesions on the lips: childhood herpes simplex associated with erythema multiforme mimics Stevens-Johnson syndrome

Erythema multiforme and Stevens-Johnson syndrome are both characterized by areas of epithelial necrosis. An important clinical feature that distinguishes the two is the extensive mucosal necrosis in Stevens-Johnson syndrome but not in erythema multiforme. Because significant and serious complications may develop with Stevens-Johnson syndrome and not with erythema multiforme, it is important to differentiate between the conditions. We describe three boys with herpes simplex virus-associated erythema multiforme who had severe necrosis of the lips develop and were initially diagnosed with Stevens-Johnson syndrome. The lip lesions were large target lesions of erythema multiforme rather than the extensive necrosis seen in Stevens-Johnson syndrome and all three had a benign course.