eMedicine Specialties > Dermatology > Reactive & Inflammatory Dermatoses

Erythema Multiforme: Follow-up

Author: Jose Antonio Plaza, MD, Director of Dermatopathology, Department of Pathology, Froedtert Hospital; Assistant Professor, Department of Pathology, Section of Dermatopathology, Medical College of Wisconsin
Coauthor(s): Victor G Prieto, MD, PhD, Director of Dermatopathology, Professor, Departments of Pathology and Dermatology, University of Texas MD Anderson Cancer Center
Contributor Information and Disclosures

Updated: May 29, 2009

Follow-up

Further Inpatient Care

Erythema multiforme (EM) major may require hospitalization for the treatment of complications and sequelae.

Inpatient & Outpatient Medications

Prophylaxis for recurrence of herpes-associated erythema multiforme (HAEM) should be considered in patients with more than 5 attacks per year. Low-dose acyclovir (200 mg qd to 400 mg bid) can be effective for recurrence of HAEM, even in subclinical HSV infection. In children,  10 mg/kg/d may be considered.28,29,30 Prophylaxis may be required for 6-12 months or longer. If unresponsive, continuous therapy with valacyclovir (500 mg bid) has been reported to be effective.31

Alternative treatments for erythema multiforme include dapsone, antimalarials, azathioprine, cimetidine, and thalidomide.32

Transfer

The most severe cases should be managed in intensive care or burn units.

Deterrence/Prevention

Sulfonamide-containing ointments should be avoided.

Complications

Most patients have an uncomplicated course, with the exception of hosts who are immunocompromised and those with secondary bacterial infections of the skin or the mucosa.

  • Severe oral involvement may be accompanied by difficulty in consuming food and fluid and can result in dehydration.
  • Ocular complications may manifest as purulent conjunctivitis, dry eyes, anterior uveitis, panophthalmitis, scarring of the conjunctivae, symblepharon, and blindness.
  • Vaginal and urethral lesions are infrequent. The erosions may cause urinary retention and phimosis. Hematocolpos is the result of genital lesions in teenage females. Severe scarring of the genitourinary tract may cause vaginal and urethral stenosis.

Prognosis

In erythema multiforme minor, the lesions ultimately subside within 2-3 weeks without scarring. The recurrence of erythema multiforme minor is common and mostly preceded by apparent or subclinical HSV infection.

Erythema multiforme major has a mortality rate of less than 5%. It usually has a more protracted course than erythema multiforme minor; clearing may require 3-6 weeks. Skin lesions usually heal with hyperpigmentation and/or hypopigmentation. Scarring is usually absent, except after secondary infection.

Two additional rare clinical forms of erythema multiforme have been reported. Continuous erythema multiforme manifests as a prolonged course with overlapping attacks and may be associated with systemic administration of glucocorticoids. Persistent erythema multiforme has a protracted clinical course over months, is commonly associated with atypical skin lesions, and is commonly resistant to conventional treatment. It has been reported in association with inflammatory bowel disease, occult renal carcinoma, persistent or reactivated Epstein-Barr virus infection, and HSV infection.

Healing of the mucosal areas is usually complete. Scars and strictures of the esophageal, urethral, vaginal, and anal mucosa rarely occur. Severe eye complications may result in permanent blindness.

Patient Education

For excellent patient education resources, visit eMedicine's Skin, Hair, and Nails Center. Additionally, see eMedicine's patient education article Life-Threatening Skin Rashes.

 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Olufunmilayo Ogundele, MD, Mark A. Silverberg, MD, FACEP, MMB, Lawrence A. Schachner, MD, and Chulabhorn Pruksachatkunakorn, MD, to the development and writing of this article.
 
The authors and editors of eMedicine also gratefully acknowledge the contributions of previous Chief Editor, William D. James, MD, to the development and writing of this article.



More on Erythema Multiforme

Overview: Erythema Multiforme
Differential Diagnoses & Workup: Erythema Multiforme
Treatment & Medication: Erythema Multiforme
Follow-up: Erythema Multiforme
Multimedia: Erythema Multiforme
References
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References

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Further Reading

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Keywords

erythema multiforme, EM, Stevens-Johnson syndrome, SJS, erythema multiforme major, EM major, erythema multiforme minor, EM minor, herpes-induced EM major, HAEM, herpes-associated erythema multiforme, herpes-associated EM, drug-induced SJS, drug-induced Stevens-Johnson syndrome

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Contributor Information and Disclosures

Author

Jose Antonio Plaza, MD, Director of Dermatopathology, Department of Pathology, Froedtert Hospital; Assistant Professor, Department of Pathology, Section of Dermatopathology, Medical College of Wisconsin
Jose Antonio Plaza, MD is a member of the following medical societies: American Medical Association and American Society for Clinical Pathology
Disclosure: Nothing to disclose.

Coauthor(s)

Victor G Prieto, MD, PhD, Director of Dermatopathology, Professor, Departments of Pathology and Dermatology, University of Texas MD Anderson Cancer Center
Victor G Prieto, MD, PhD is a member of the following medical societies: American Association for the Advancement of Science, American Medical Association, American Society for Clinical Pathology, American Society of Dermatopathology, College of American Pathologists, European Society of Pathology, International Society of Dermatopathology, Society for Investigative Dermatology, and United States and Canadian Academy of Pathology
Disclosure: Nothing to disclose.

Medical Editor

Evan R Farmer, MD, Professor of Dermatology, Johns Hopkins University School of Medicine, Clinical Professor of Pathology, Virginia Commonwealth University School of Medicine; Consulting Staff, Department of Dermatology, Johns Hopkins Hospital, VCU Health Services
Evan R Farmer, MD is a member of the following medical societies: American Academy of Dermatology, American Dermatological Association, American Medical Association, American Society of Dermatopathology, and International Society of Dermatology
Disclosure: Nothing to disclose.

Pharmacy Editor

Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center
Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Warren R Heymann, MD, Head, Division of Dermatology, Professor, Department of Internal Medicine, University of Medicine and Dentistry of New Jersey
Warren R Heymann, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

CME Editor

Joel M Gelfand, MD, MSCE, Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania
Joel M Gelfand, MD, MSCE is a member of the following medical societies: Society for Investigative Dermatology
Disclosure: AMGEN Consulting fee Consulting; AMGEN Grant/research funds None; Genentech Consulting fee Consulting; Centocor Consulting fee Consulting; Centocor Grant/research funds None; Covance Consulting fee Consulting; Shire  Consulting

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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