Erythema multiforme: diagnosis, clinical manifestations and treatment in a retrospective study of 22 patients

Erythema multiforme: A retrospective study of etiologies, clinical manifestations, and treatments

Background/purpose

Erythema multiforme (EM) is considered a hypersensitivity reaction associated with drugs and infections, and remains underestimated due to the lack of precise classification and diagnostic criteria. The aim of this study was to evaluate the triggering factors and clinical manifestations of EM and to present our experience in the diagnosis and management of this disorder.

Materials and methods

All patient records were reviewed, and records of patients admitted, diagnosed, and treated with EM were retrieved. Data on age, gender, medical history, triggering factor(s), clinical form, mucosal/cutaneous involvement, affected oral site(s), recurrence, and treatment were collected. The data were analyzed statistically at a significance level set at P < 0.05.

Results

A total of 36 EM patients were studied. The triggering factor was identified as infection in 25 %, drugs in 16.7 %, infections and drugs in 41.7 %, and none in 16.7 % of the 36 EM patients. EM minor was diagnosed in 77.8 % of the patients. Labial mucosa (86.1 %) was the most commonly affected oral site. Most patients were treated with topical steroids (25 %). No significant differences were detected between demographic and clinical characteristics with regards to gender, triggering factor, and the number of affected oral sites (P > 0.05).

Conclusion

The results of this study, based on the data from 36 EM patients with oral involvement treated at our clinic, can guide dentists in this regard and may be considered as an epidemiological source for the region.

Dermatologic and Ophthalmologic Treatment of Erythema Multiforme Major: A Case Report

Erythema multiforme major (EMM) is a rare type IV cytotoxic reaction targeting keratinocytes of the mucosal surfaces and the dermis. Dusky, targetoid lesions with central clearing are classically present, which may become blistered and rupture. The disease is usually self-limited and managed with supportive care and treatment of the underlying condition. The most common triggering factors are adverse reactions to medications, herpes simplex virus (HSV), and Mycoplasma pneumoniae. Rapid recognition of EMM is essential to avoid long-term complications. This case presents a 39-year-old male with a unique history of recent non-steroidal anti-inflammatory drug (NSAID) use, past infection with HSV-1, and an acute Mycoplasma pneumoniae infection. The patient developed painful lesions on the skin, oral mucosa, ocular surfaces, and urethra. The painful lesions caused complications with feeding and voiding. Initially, the triggering event was unclear. Supportive care was started. NSAIDs were discontinued and similarly-structured drugs were avoided. Treatments targeting Mycoplasma pneumoniae and HSV-1 were initiated while lab results were pending. Once the results returned, the treatment regimen of corticosteroids for inflammation, acyclovir for HSV-1, and azithromycin for Mycoplasma pneumoniae was continued. Vaseline was applied to open lesions. The patient was also treated with mouthwash consisting of aluminum (Al) hydroxide/magnesium (Mg) hydroxide/simethicone (400 mg/400 mg/40 mg). Topical 2% lidocaine gel with applicator was used to assist with urinary discomfort during voiding. Fentanyl was used for pain control. The patient successfully recovered and was discharged to follow-up with ophthalmology. Long-term sequelae including trichiasis, symblepharon, and punctal stenosis were noted during follow-up appointments.

From HSV infection to erythema multiforme through autoimmune crossreactivity

Scientific and clinical data indicate that human herpes simplex virus 1 (HSV1) and, at a lesser extent, human herpes simplex virus 2 (HSV2) are factor(s) implicated in the development of erythema multiforme (EM). With a focus on oral EM, the present structured review of proteomic and epitope databases searched for the molecular basis that might link HSV1 and HSV2 infections to EM. It was found that a high number of peptides are shared between the two HSVs and human proteins related to the oral mucosa. Moreover, a great number of the shared peptides are also present in epitopes that have been experimentally validated as immunopositive in the human host. The results suggest the involvement of HSV infections in the induction of oral EM via a mechanism of autoimmune cross-reactivity and, in particular, highlight a potential major role for 180kDa bullous pemphigoid antigen and HSV1 infection in the genesis of crossreactions potentially conducive to EM.

Erythema multiforme induced by alendronate sodium in a geriatric patient: A case report and review of the literature

Erythema multiforme is an uncommon acute inflammatory disorder caused by exposure to microbes or drugs. Erythema multiforme minor typically affects only one mucosa and can be associated with symmetrical target skin lesions on the extremities. The disease usually occurs in patients in their 3rd and 4th decade of life, but can also affect children and adolescents. Alendronate sodium has been approved for the prevention and treatment of osteoporosis in postmenopausal women, but is associated with adverse events. This study reports and discusses a case of erythema multiforme minor. In addition, a literature search of articles published in PubMed-Medline was performed. The case was a 96-year-old woman who had taken alendronate. Intraoral clinical examination demonstrated hypersalivation and macrocheilia of the lower lip, associated with an ill-defined ulcer with erythematous borders measuring 20 mm in greatest diameter and covered with serofibrinous exudates. The aging of the population in developed and developing countries has increased the use of alendronate sodium to prevent osteoporosis and clinicians should be aware of possible oral adverse events associated with this drug.

Key words:Adverse events, erythema multiforme, therapeutics, diagnosis, alendronate.

Immune-mediated diseases: what can be found in the oral cavity?

Immune-mediated diseases frequently affect oral mucosa, which may often be the first site of clinical manifestation. In this review, we describe the most important oral lesions related to inflammatory disorders and present their management and novel therapies. The review is based on an open PubMed literature search from 1980 to 2012 with relevant keywords. Pemphigus vulgaris, oral lichen planus, cicatricial pemphigoid, erythema multiforme, Stevens-Johnson syndrome, systemic lupus erythematosus, Sjögren's syndrome, and linear IgA dermatosis are the immune-mediated diseases with oral manifestations discussed. Etiology is unknown in most of these diseases, but recently some of them have been found to share common genes. Modern treatment of these diseases is based on drugs that interfere along the pathogenic mechanisms instead of the still commonly used palliative measures. However, the immunomodulatory drugs may also cause oral side effects, complicating the clinical picture. Therefore, consulting dental or oral medicine specialists can be necessary in some cases with various immune-mediated diseases.

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.

Erythema multiforme in children: the steroid debate

QUESTION

In my office I occasionally see children who have rashes with "target lesions" and who are diagnosed with erythema multiforme (EM). When should these children receive steroids, and when should the illness be allowed to follow its natural course without steroid treatment?

ANSWER

Erythema multiforme is relatively common in children. Current recommendations suggest not to treat EM minor with systemic steroids and that topical steroids might be of benefit. The use of systemic steroids for EM major remains controversial, as there is evidence both for and against treatment, and no randomized controlled trials have been done. Further studies need to address the benefit of steroids, and in the interim, physicians should decide on a treatment based on the severity of EM and in consultation with a dermatologist, if available.