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General Medicine

Erythema Multiforme

Losika Sivaganeshan, MD, MPH and Pradeepa P. Vimalachandran, MD, MPH Reviewed 06/2019
 


BASICS

  • Erythema multiforme (EM) is relatively common, acute, recurrent, self-limiting inflammatory disease.

    • Mostly (~90% of cases) triggered by infectious agents (up to 50% by herpes simplex virus [HSV...

DIAGNOSIS

Clinical 

HISTORY

  • Absent or mild prodromal symptoms

  • Acute, self-limiting episodic course

  • History of new medication

  • Preceding HSV infection 10 to 15 days before the skin eruptions

  • Rash involving th...

TREATMENT

GENERAL MEASURES

  • Step 1: Discontinue or treat inciting factor (1).

  • Wound care for severe cases with epidermal detachment

  • Oral lesions should be addressed to insure maintenance of PO intake. Thi...

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Patient Monitoring

  • The disease is self-limiting.

  • Complications are rare, with no mortality.

DIET

As tolerated, with increased fluid intake 

PATIENT EDUCATION

  • The diseas...

REFERENCES

1
Sokumbi O, Wetter DA. Clinical features, diagnosis, and treatment of erythema multiforme: a review for the practicing dermatologist. Int J Dermatol.  2012;51(8):889–902. [View Abstrac...

ADDITIONAL READING

  • Sola CA, Beute TC. Erythema multiforme. J Spec Oper Med.  2014;14(3):90–92. [View Abstract on OvidMedline]

  • Wetter DA, Davis MD. Recurrent erythema multiforme: clinical character...

CODES

ICD10

  • L51.9 Erythema multiforme, unspecified

  • L51.8 Other erythema multiforme

  • L51.0 Nonbullous erythema multiforme

ICD9

  • 695.10 Erythema multiforme, unspecified

  • 695.11 Erythema multiforme minor

  • 695.12 Er...

CLINICAL PEARLS

  • EM is diagnosed clinically by careful review of the history, thorough detailed physical exam, and by excluding other similar disorders. No lab tests are required for the diagnosis.

  • Typi...

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dermatitis herpetiformis
dermatitis herpetiformis
Figure 1-3 Ill-appearing child with Stevens-Johnson syndrome. (Courtesy of Joseph Lopreiato, MD.)
Figure 1-3 Ill-appearing child with Stevens-Johnson syndrome. (Courtesy of Joseph Lopreiato, MD.)
Eruption occurring in a young man who received amoxicillin just prior to mononucleosis diagnosis
Eruption occurring in a young man who received amoxicillin just prior to mononucleosis diagnosis
Close-up of previous patient
Close-up of previous patient
Erythema multiforme–like eruption on the patient's arm. Notice the dusky, target-like appearance. (Dermik Laboratories, Inc.)From Sauer G. C., Hall J. C. [1996]. Manual of skin diseases [7th ed.]. Philadelphia: Lippincott-Raven.
Erythema multiforme–like eruption on the patient's arm. Notice the dusky, target-like appearance. (Dermik Laboratories, Inc.)From Sauer G. ...
Erythema multiforme. Target lesions (A), which consist of a red ring around a clear area (sometimes with a central bull's eye), characterize erythema multiforme. In severe cases (B, C) or with involvement of the mucous membranes (Stevens–Johnson syndrome), vesicles may appear.From Fleisher GR, MD, Ludwig S, MD, Baskin MN, MD. Atlas of Pediatric Emergency Medicine. Philadelphia: Lippincott Williams & Wilkins, 2004.
Erythema multiforme. Target lesions (A), which consist of a red ring around a clear area (sometimes with a central bull's eye), characteriz...
Urticaria - child with 2 day of itching, evanescent eruption
Urticaria - child with 2 day of itching, evanescent eruption
FIGURE 7.18 Urticaria. Dermal vasodilatation occurs, with no epidermal change (scale).
FIGURE 7.18 Urticaria. Dermal vasodilatation occurs, with no epidermal change (scale).
1.70. One month after the acute onset of Stevens-Johnson syndrome, there is still active conjunctival and corneal inflammation and already significant symblepharon formation.
1.70. One month after the acute onset of Stevens-Johnson syndrome, there is still active conjunctival and corneal inflammation and already ...
FIG. 2.13. Stevens-Johnson syndrome. A: Adolescent with Stevens-Johnson syndrome secondary to sulfonamides. Note the involvement of mucous membranes of the mouth. B: Same child. Note the distribution of lesions.
FIG. 2.13. Stevens-Johnson syndrome. A: Adolescent with Stevens-Johnson syndrome secondary to sulfonamides. Note the involvement of mucous ...
FIG. 6.7. Erythema multiforme. Target lesions (A), which consist of a red ring around a clear area (sometimes with a central bull's eye), characterize erythema multiforme. In severe cases (B, C) or with involvement of the mucous membranes (Stevens-Johnson syndrome), vesicles may appear.
FIG. 6.7. Erythema multiforme. Target lesions (A), which consist of a red ring around a clear area (sometimes with a central bull's eye), c...
Erythema multiforme.Courtesy of George A. Datto, III, MD
Erythema multiforme.Courtesy of George A. Datto, III, MD
Erythema multiforme. Steroid-responsive target papules, characterized by central bullae with surrounding erythema, appeared after antibiotic therapy.Elder AD, Elenitsas R, Johnson BL, et al: Synopsis and Atlas of Lever's Histopathology of the Skin. Lippincott Williams & Wilkins, Philadelphia, 1999, p 2, clin. fig. IA1; p 163, clin. fig. IVE3; p 167,
Erythema multiforme. Steroid-responsive target papules, characterized by central bullae with surrounding erythema, appeared after antibioti...
(A) Bulla, (B) Target (or iris) lesion (in erythema multiforme)From Bickley, LS and Szilagyi, P. Bates' Guide to Physical Examination and History Taking, 8th Ed. Philadelphia: Lippincott Williams & Wilkins 2003
(A) Bulla, (B) Target (or iris) lesion (in erythema multiforme)From Bickley, LS and Szilagyi, P. Bates' Guide to Physical Examination and H...
Erythema multiforme major (Stevens-Johnson Syndrome). Bullae and hemorrhagic crusts are noted on the lips of this patient. He has targetoid lesions elsewhere on his body. From Goodheart HP. Goodheart's Photoguide to Common Skin Disorders: Diagnosis and Management, 3rd Edition. Philadelphia: Lippincott Williams & Wilkins, 2009.
Erythema multiforme major (Stevens-Johnson Syndrome). Bullae and hemorrhagic crusts are noted on the lips of this patient. He has targetoid...
Figure 14.41. Erythema multiforme. A. Early. B. Late.
Figure 14.41. Erythema multiforme. A. Early. B. Late.
Figure 72-8 Hemorrhagic ulcerative stomatitis in SJS. (Courtesy of Joseph Lopreiato, MD.)
Figure 72-8 Hemorrhagic ulcerative stomatitis in SJS. (Courtesy of Joseph Lopreiato, MD.)
FIGURE 61-20 Erythema-multiforme–like eruption on the patient's arm. Notice the dusky, target-like appearance. (Dermik Laboratories, Inc.) (Sauer G.C., Hall J.C. [1996]. Manual of skin diseases [7th ed.]. Philadelphia: Lippincott-Raven)
FIGURE 61-20 Erythema-multiforme–like eruption on the patient's arm. Notice the dusky, target-like appearance. (Dermik Laboratories, Inc.) ...
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