Variants of Erythema Multiforme: A Case Report and Literature Review

Diffusive mediator feedbacks control the health-to-disease transition of skin inflammation

The spatiotemporal dynamics of inflammation provide vital insights into the understanding of skin inflammation. Skin inflammation primarily depends on the regulatory feedback between pro- and anti-inflammatory mediators. Healthy skin exhibits fading erythema. In contrast, diseased skin exhibits expanding erythema with diverse patterns, which are clinically classified into five types: circular, annular, arcuate, gyrate, and polycyclic. Inflammatory diseases with expanding erythema are speculated to result from the overproduction of pro-inflammatory mediators. However, the mechanism by which feedback selectively drives the transition from a healthy fading erythema to each of the five types of diseased expanding erythema remains unclear. This study theoretically elucidates the imbalanced production between pro- and anti-inflammatory mediators and prospective treatment strategies for each expanding pattern. Our literature survey showed that eleven diseases exhibit some of the five expanding erythema, thereby suggesting a common spatiotemporal regulation underlying different patterns and diseases. Accordingly, a reaction-diffusion model incorporating mediator feedback reproduced the five observed types of diseased expanding and healthy fading patterns. Importantly, the fading pattern transitioned to the arcuate, gyrate, and polycyclic patterns when the productions of anti-inflammatory and pro-inflammatory mediators were lower and higher, respectively than in the healthy condition. Further depletion of anti-inflammatory mediators caused a circular pattern, whereas further overproduction of pro-inflammatory mediators caused an annular pattern. Mechanistically, the bistability due to stabilization of the diseased state exhibits circular and annular patterns, whereas the excitability exhibits the gyrate, polycyclic, arcuate, and fading patterns as the threshold of pro-inflammatory mediator concentration relative to the healthy state increases. These dynamic regulations of diffusive mediator feedback provide effective treatment strategies for mediator production wherein skins recover from each expanding pattern toward a fading pattern. Thus, these strategies can estimate disease severity and risk based on erythema patterns, paving the way for developing noninvasive and personalized treatments for inflammatory skin diseases.

Drug-Induced Erythema Multiforme

Erythema multiforme (EM) is an acute inflammatory, mucocutaneous, psychosomatic, and vesiculobullous condition that varies from minor to major forms. The acral distribution of target lesions is a characteristic of this condition. The aetiology of erythema multiforme is multifactorial. 90% of the cases are triggered by a herpes infection, whereas 10% occur secondary to drug intake. The offending drugs include nonsteroidal anti-inflammatory drugs, antibiotics, and anticonvulsants. The present case series discusses four cases of drug-induced erythema multiforme and their management.

A 14-year-old boy with severe erythema multiforme due to amoxicillin

The most common cause of erythema multiforme (EM) in children is infectious diseases which account for approximately 90% of cases. Drug eruptions are another common cause. Here we are reporting about a male patient aged 14 years with lymphadenitis who developed severe diffuse erythema during the course of treatment with medications including several antibiotics and nonsteroidal anti-inflammatory drugs (NSAIDs). Based on the pathological findings of the skin biopsy, the skin rash was due to EM. Upon investigating the underlying cause of EM, viral antibody was positive for Coxsackie A6, lymphocyte transformation testing (LTT) was positive for one of the NSAIDs, and the patch test (PT) was positive for amoxicillin. Based on the pattern of distribution of the skin rash, the cause of EM was considered to be drug-induced eruption due to amoxicillin. In this case, we did not derive a diagnosis of drug eruption without investigating the possibility of drug induction, because most cases of EM in children are induced by infection and the antibody against Coxsackie A6 was elevated. To diagnose the possibility of amoxicillin-induced EM, it was important to distinguish between the distribution patterns of infectious versus drug-induced EM and to evaluate the possibility of drug induction by both LTT and PT. If the diagnosis of amoxicillin-induced EM, had not been made, the potential recurrence of EM with amoxicillin could have occurred.

Recurrent Erythema Multiforme Major Following COVID-19 Infection

Erythema multiforme (EM) is a rare and potentially serious skin condition that can present as a myriad of mucocutaneous lesions. EM can be commonly confused with other cutaneous etiologies, leading to misdiagnosis and delay in proper treatment. This paper describes a case of recurrent erythema multiforme following COVID-19 infection in a 34-year-old male with no prior medical history. The patient had an extensive rash of the oral and genital mucosal areas, diffuse cutaneous involvement, and an extended length of recovery. This unexpected association of EM and COVID-19 provides additional insight into the limited research available regarding the correlation between these two pathologies.

Promising Natural Products in New Drug Design, Development, and Therapy for Skin Disorders: An Overview of Scientific Evidence and Understanding Their Mechanism of Action

The skin is the largest organ in the human body, composed of the epidermis and the dermis. It provides protection and acts as a barrier against external menaces like allergens, chemicals, systemic toxicity, and infectious organisms. Skin disorders like cancer, dermatitis, psoriasis, wounds, skin aging, acne, and skin infection occur frequently and can impact human life. According to a growing body of evidence, several studies have reported that natural products have the potential for treating skin disorders. Building on this information, this review provides brief information about the action of the most important in vitro and in vivo research on the use of ten selected natural products in inflammatory, neoplastic, and infectious skin disorders and their mechanisms that have been reported to date. The related studies and articles were searched from several databases, including PubMed, Google, Google Scholar, and ScienceDirect. Ten natural products that have been reported widely on skin disorders were reviewed in this study, with most showing anti-inflammatory, antioxidant, anti-microbial, and anti-cancer effects as the main therapeutic actions. Overall, most of the natural products reported in this review can reduce and suppress inflammatory markers, like tumor necrosis factor-alpha (TNF-α), scavenge reactive oxygen species (ROS), induce cancer cell death through apoptosis, and prevent bacteria, fungal, and virus infections indicating their potentials. This review also highlighted the challenges and opportunities of natural products in transdermal/topical delivery systems and their safety considerations for skin disorders. Our findings indicated that natural products might be a low-cost, well-tolerated, and safe treatment for skin diseases. However, a larger number of clinical trials are required to validate these findings. Natural products in combination with modern drugs, as well as the development of novel delivery mechanisms, represent a very promising area for future drug discovery of these natural leads against skin disorders.

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.

Erythema Multiforme-Like Presentation in an Asymptomatic COVID-19 Patient

In clinical practice, there are a lot of variations in disease manifestations. Diseases are constantly evolving, and one negative test cannot completely rule out a disease. Erythema multiforme (EM) is a common mucocutaneous disease that can be linked to a lot of etiologies, with the most common being herpes simplex virus (HSV) types 1 and 2, Mycoplasma pneumoniae, and the use of various drugs. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a new virus, and traditionally it is not the first differential for EM eruptions. We report the case of a 52-year-old female patient with a history of multiple drug use, pneumonia-like symptoms, an initial negative viral panel for SARS-CoV-2, followed by a positive polymerase chain reaction (PCR) test, asymptomatic coronavirus disease 2019 (COVID-19) clinical course, and break-out of typical targetoid lesions of EM. Throughout her hospital stay, the patient maintained her oxygenation levels and improved clinically with steroids and symptomatic treatment. She regained her health and was counseled to quit smoking, alcohol, and opioid usage at the time of discharge from the hospital, and a regular follow-up with her primary care practitioner (PCP) was advised.

Recent Updates in the Treatment of Erythema Multiforme

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

Oral Manifestations of Exudative Erythema Multiforme in a Patient with COVID-19

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a viral infection with multiorgan manifestations that may affect the oral mucosa. The full range of oral manifestations of COVID-19 are unknown, and there are limited reports describing the features of oral manifestations of COVID-19, including taste loss, oral lesions, and xerostomia. The aim of this study is to report a case of oral erythema multiforme (EM) manifesting as oral, lip, and skin lesions in a COVID-19 patient. The presence of oral lesions in the late stage of COVID-19 could be related to weak patient immunity or related therapies.

Gingival proliferative growth - stress and cytoarchitecture related with fixed and mobile orthodontic therapy

The fixed orthodontic measures taken induce significant stress to the gingival growth process during arch wire maneuvers of aligning and leveling. We observed, for a period of one to four years, fixed orthodontic devices in 80 human subjects. From these, we selected 44 subjects (22 women and 22 men) where the inflammatory process exhibited following the orthodontic fixed treatment, and with vacuum-formed orthodontic retainers (VFR) succeeding to fixed treatment. Samples were collected from each patient and histological and immunohistochemical (IHC) methodology was made to analyze the cytoarchitecture. Statistics were made after one-way analysis of variance (ANOVA), with the Bonferroni’s correction. The IHC examination performed in the early stage revealed the presence in the inflammatory infiltrate of CD8-type T-lymphocytes, and of dendritic cells in large numbers. The examination performed in the late stage revealed the presence in the inflammatory infiltrate of CD20-type B-lymphocytes, which are mature cells capable of immunoglobulin synthesis, their activation being an important step in the maturation of the antibody response. The stress generated by arch wires in both genders was significantly higher than in the case of VFR. This observation was pointed out also by the cytohistological investigation outcome but was also based on an original scale conceived by our research team, following gingival hyperplasia evaluation. Also, with statistical significance, the comparative obtained values for men (p=0.01) and for women (p=0.001) illustrate clinical observations, allowing to affirm that, in our case, men were more stressed in bearing arch wire devices (AWD) and VFR, in comparison with women.