Erythema

Multiforme
Gwyneth Colis DMD4A
 Definition
Erythema multiforme (EM) is an acute,
self-limited, and sometimes recurring
skin condition that is considered to be
a type IV hypersensitivity reaction
associated with certain infections,
medications, and other various triggers.
Characterized by erythema, papula,
and blister which involves of skin and
mucosa.
Its a immune reaction of skin that
develops in response to a viral infection
 Etiology & Pathogensesis
Unknown
Hypersensitivity reaction is suspected
Precipitating factors can be identified in 50% of the cases
(infection & drugs)
Other factors which trigger EM (Malignancy, Vaccination,
Autoimmune disease, Radiotherapy)
Infection frequently reported included (Herpes simples (HSV types
I & II),TB, Histoplasmosis)
Various types of drugs that precipitate EM: Barbiturates &
Sulfonamides
 EM MINOR - localized eruption of
the skin with mild or no mucosal
involvement
EM MAJOR - skin and mucosal
erosions of raised atypical
TYPES OF target lesions and usually

ERYTHEMA
located on extremities and/or
on the face.

MULTIFORME STEVENS-JOHNSON SYNDROME -

skin & mucosal erosion plus
widespread distribution f flay
atypical targets or purpuric
macules
TOXIC EPIDERMAL NECROLYSIS
 a major variant of EM
Mouth, eyes, skin, genitalia & occasionally the
esophagus & respiratory tract may be seen
Stevens- Systemic signs & symptoms are more pronounced
Cutaneous & mucosal lesions are more extensive
Johnson
Clinical features
Syndrome Lips my become encrusted
Oral lesions may cause exquisite pain
Superficial ulceration, often preceded by a bullae is
common to all affected sites
Ocular inflammation (Conjunctivitis & uveitis) may
lead to scarring & blindness in some patients
 very serious, often fatal, bullous drug eruption
So severe that large sheets of skin peel off-
Toxic appearance of a widespread scalding burn
Oral erosions may also occur
Epidermal Considered to be a confluent form of Stevens-
Johnson syndrome.
Necrolysis TENS must be differentiated from the Staphylococcal
Scalded Skin Syndrome (SSS) - clinically similar even
(TENS) though the latter is a milder disease with a better
prognosis
Steven Johnson Toxic Epidermal
Syndrome Necrolysis
 Epidemiology
Male Female = 3:2
Occurs in the young / adoloscents
Recurrent in 30%
Familial clustering s/o Infective Etiology
CAUSES
INFECTIONS DRUGS
Cytomegalovirus Epstein-Barr Antibiotics
virus Antiepeliptics
Barbiturates
Hepatitis C virus
Nonsteroidal anti-inflammatory drugs
Herpes simplex virus type 1,
Phenothiazines
herpes simplex virus type 2 Statins
Influenza virus Sulfonamides
Mycoplasma pneumoniae Tumor necrosis factor-a inhibitors
Vulvovaginal candidiasis Vaccines

OTHER CONDITIONS
Inflammatory bowel disease
Malignancy
Mestruation
Clinical Features
Acute self-limiting process that
affects the skin &/or mucous
membranes
25-50% of the patients with
cutaneous EM will have oral
manifestations
May be chronic in nature or recurrent
acute type
In recurrent cases, prodromal
symptoms
Young adults
Often develop in the spring or fall
Clinical Features
Multiple & varied clinical appearances with
cutaneous manifestations (multiforme)
Target or iris lesion is the classic skin lesion
of EM
Typically, the extremities are involved
Usually in symmetric distribution
Other types of skin manifestations include:
macules, papules, vesicles, bullae, urticarial
plaques
Orally, seen as ulcerative disease
Varying from a few aphthous-type lesions
to multiple, superficial, widespread ulcers
Areas involved are lips, buccal mucosa,
palate & tongue
Histopathology
No specific or consistent
microscopic pattern
Dermal vessels shown to have
Ig M complement and fibrin in
their walls- this support an
immune-complex vasculitis
cause of EM
Differential Diagnosis
Target or iris skin lesion is present, clinical diagnosis is
straightforward
If skin lesion is absent, it has to be compared with primary
HSV infections, aphthous ulcers, pemphigus vulgaris, bullous
pemphigoid & erosive lichen planus
Diagnosis
To diagnose EM, the ff. should be present:
General lack of systemic symptoms
Favored oral location of lips, buccal mucosa, tongue, &
palate
Larger sized ulcers- not precede by vesicles
Presence of target skin lesions
History of recent drug ingestion or infection
Prevention
Preventing erythema includes
proper treatment of underlying
diseases that are caused by
medications, limiting exposure
to the sun, proper immune
system support, and good
hygiene to prevent secondary
infection.
Treatment
Identification of the cause should be made
if drug is suspected, it should be withdrawn
Symptomatic treatment – mild cases
Topical corticosteroids with anti-fungal, oral antihistamine,
soothing mouthwashes, & oral antacids.
In severe cases, moderate dose of systemic corticosteroids
may be used to shorten the course of the disease & abort
recurrences or reduce its intensity
Supportive measures to provide patients with substantial
benefits: Oral irrigation, Adequate fluid intake, & Use of
antipyretics