eMedicine Specialties > Dermatology > Reactive & Inflammatory Dermatoses

Erythema Multiforme: Treatment & Medication

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

Treatment

Medical Care

The cause of the erythema multiforme (EM) should be identified, if possible. If a drug is suspected, it must be withdrawn as soon as possible. Infections should be appropriately treated after cultures and/or serologic tests have been performed. Suppression of herpes simplex virus (HSV) can prevent HSV-associated erythema multiforme, but antiviral treatment started after the eruption of erythema multiforme has no effect on the course of the erythema multiforme.

For all forms of erythema multiforme, the most important treatment is usually symptomatic, including oral antihistamines, analgesics, local skin care, and soothing mouthwashes. Topical steroids may be considered.

The use of liquid antiseptics, such as 0.05% chlorhexidine, during bathing helps prevent superinfection. Topical treatment, including that for genital involvement, may be performed with a gauze dressing or a hydrocolloid. Local supportive care for eye involvement is important and includes topical lubricants for dry eyes, sweeping of conjunctival fornices, and removal of fresh adhesions.

A liquid diet and intravenous fluid therapy may be necessary. Oral antacids may be helpful for discrete oral ulcers. Electrolytes and nutritional support should be started as soon as possible.

Systemic corticosteroid therapy is controversial, and some believe it may predispose to complications. Beneficial effects with hemodialysis, plasmapheresis, cyclosporin, immunoglobulin, levamisole, thalidomide, dapsone, and cyclophosphamide have been documented in case reports.

Consultations

  • Dermatologist - For diagnosis and management
  • Internal medicine specialist or a pediatric specialist  - For evaluation of the underlying causes of disorders and systemic sequelae
  • Early consultation with an ophthalmologist - Evaluation and management of ocular involvement

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

  1. Assier H, Bastuji-Garin S, Revuz J, Roujeau JC. Erythema multiforme with mucous membrane involvement and Stevens-Johnson syndrome are clinically different disorders with distinct causes. Arch Dermatol. May 1995;131(5):539-43. [Medline].

  2. Bastuji-Garin S, Rzany B, Stern RS, Shear NH, Naldi L, Roujeau JC. Clinical classification of cases of toxic epidermal necrolysis, Stevens-Johnson syndrome, and erythema multiforme. Arch Dermatol. Jan 1993;129(1):92-6. [Medline].

  3. Cote B, Wechsler J, Bastuji-Garin S, Assier H, Revuz J, Roujeau JC. Clinicopathologic correlation in erythema multiforme and Stevens-Johnson syndrome. Arch Dermatol. Nov 1995;131(11):1268-72. [Medline].

  4. Fritsch PO, Ruiz-Maldonado R, Erythema multiforme. Stevens-Johnson syndrome and toxic epidermal necrolysis. In: Freedberg IM, Irwin M, Eisen AZ, Wolff K, Austen KF, Goldsmith LA, Katz SI, editors. Fitzpatrick's Dermatology in General Medicine. 6th edition. New York: McGraw-Hill; 2003:543-57.

  5. Fritsh PO, Elias PM. Erythema multiforme and toxic epidermal necrolysis. In: Fitzpatrick TB, et al, eds. Fitzpatrick's Dermatology in General Medicine. New York: McGraw-Hill; 1993:585-600.

  6. Roujeau JC. Stevens-Johnson syndrome and toxic epidermal necrolysis are severity variants of the same disease which differs from erythema multiforme. J Dermatol. Nov 1997;24(11):726-9. [Medline].

  7. Huff JC. Erythema multiforme and latent herpes simplex infection. Semin Dermatol. Sep 1992;11(3):207-10. [Medline].

  8. Orton PW, Huff JC, Tonnesen MG, Weston WL. Detection of a herpes simplex viral antigen in skin lesions of erythema multiforme. Ann Intern Med. Jul 1984;101(1):48-50. [Medline].

  9. Schofield JK, Tatnall FM, Brown J, McCloskey D, Navarrete C, Leigh IM. Recurrent erythema multiforme: tissue typing in a large series of patients. Br J Dermatol. Oct 1994;131(4):532-5. [Medline].

  10. Kämpgen E, Burg G, Wank R. Association of herpes simplex virus-induced erythema multiforme with the human leukocyte antigen DQw3. Arch Dermatol. Sep 1988;124(9):1372-5. [Medline].

  11. Lam NS, Yang YH, Wang LC, Lin YT, Chiang BL. Clinical characteristics of childhood erythema multiforme, Stevens-Johnson syndrome and toxic epidermal necrolysis in Taiwanese children. J Microbiol Immunol Infect. Dec 2004;37(6):366-70. [Medline].

  12. Wolkenstein P, Carriere V, Charue D, et al. A slow acetylator genotype is a risk factor for sulphonamide-induced toxic epidermal necrolysis and Stevens-Johnson syndrome. Pharmacogenetics. Aug 1995;5(4):255-8. [Medline].

  13. Khafaga YM, Jamshed A, Allam AA, et al. Stevens-Johnson syndrome in patients on phenytoin and cranial radiotherapy. Acta Oncol. 1999;38(1):111-6. [Medline].

  14. Wu CC, Tsai CN, Wong WR, Hong HS, Chuang YH. Early congenital syphilis and erythema multiforme-like bullous targetoid lesions in a 1-day-old newborn: detection of Treponema pallidum genomic DNA from the targetoid plaque using nested polymerase chain reaction. J Am Acad Dermatol. Aug 2006;55(2 Suppl):S11-5. [Medline].

  15. Martire B, Foti C, Cassano N, Buquicchio R, Del Vecchio GC, De Mattia D. Persistent B-cell lymphopenia, multiorgan disease, and erythema multiforme caused by Mycoplasma pneumoniae infection. Pediatr Dermatol. Nov-Dec 2005;22(6):558-60. [Medline].

  16. Grosber M, Alexandre M, Poszepczynska-Guigne E, Revuz J, Roujeau JC. Recurrent erythema multiforme in association with recurrent Mycoplasma pneumoniae infections. J Am Acad Dermatol. May 2007;56(5 Suppl):S118-9. [Medline].

  17. Pavlovic MD, Karadaglic DM, Kandolf LO, Mijuskovic ZP. Persistent erythema multiforme: a report of three cases. J Eur Acad Dermatol Venereol. Jan 2001;15(1):54-8. [Medline].

  18. Carducci M, Latini A, Acierno F, Amantea A, Capitanio B, Santucci B. Erythema multiforme during cytomegalovirus infection and oral therapy with terbinafine: a virus-drug interaction. J Eur Acad Dermatol Venereol. Mar 2004;18(2):201-3. [Medline].

  19. Gonzalez-Delgado P, Blanes M, Soriano V, Montoro D, Loeda C, Niveiro E. Erythema multiforme to amoxicillin with concurrent infection by Epstein-Barr virus. Allergol Immunopathol (Madr). Mar-Apr 2006;34(2):76-8. [Medline].

  20. Nettis E, Giordano D, Pierluigi T, Ferrannini A, Tursi A. Erythema multiforme-like rash in a patient sensitive to ofloxacin. Acta Derm Venereol. 2002;82(5):395-6. [Medline].

  21. Mockenhaupt M, Viboud C, Dunant A, et al. Stevens-Johnson syndrome and toxic epidermal necrolysis: assessment of medication risks with emphasis on recently marketed drugs. The EuroSCAR-study. J Invest Dermatol. Jan 2008;128(1):35-44. [Medline].

  22. Thami GP, Kaur S, Kanwar AJ. Erythema multiforme due to griseofulvin with positive re-exposure test. Dermatology. 2001;203(1):84-5. [Medline].

  23. Hong SJ, Chang CH. Erythema multiforme-like generalized allergic contact dermatitis caused by Alpinia galanga. Contact Dermatitis. Feb 2006;54(2):118-20. [Medline].

  24. Werchniak AE, Schwarzenberger K. Poison ivy: an underreported cause of erythema multiforme. J Am Acad Dermatol. Nov 2004;51(5 Suppl):S159-60. [Medline].

  25. Cohen DM, Bhattacharyya I. Cinnamon-induced oral erythema multiformelike sensitivity reaction. J Am Dent Assoc. Jul 2000;131(7):929-34. [Medline].

  26. Mayumi M, Heike T, Mikawa H. Transient selective C4 deficiency of infancy. Lancet. Mar 21 1992;339(8795):752. [Medline].

  27. Aydogan K, Karadogan S, Balaban Adim S, Tunali S. Lupus erythematosus associated with erythema multiforme: report of two cases and review of the literature. J Eur Acad Dermatol Venereol. Sep 2005;19(5):621-7. [Medline].

  28. Huff JC. Acyclovir for recurrent erythema multiforme caused by herpes simplex. J Am Acad Dermatol. Jan 1988;18(1 Pt 2):197-9. [Medline].

  29. Lynn WA, Davidson RN, Wansbrough-Jones MH. Successful use of oral acyclovir to prevent herpes simplex-associated erythema multiforme. J Infect. Sep 1987;15(2):192-3. [Medline].

  30. Tatnall FM, Schofield JK, Leigh IM. A double-blind, placebo-controlled trial of continuous acyclovir therapy in recurrent erythema multiforme. Br J Dermatol. Feb 1995;132(2):267-70. [Medline].

  31. Kerob D, Assier-Bonnet H, Esnault-Gelly P, Blanc F, Saiag P. Recurrent erythema multiforme unresponsive to acyclovir prophylaxis and responsive to valacyclovir continuous therapy. Arch Dermatol. Jul 1998;134(7):876-7. [Medline].

  32. Kürkçüoglu N, Alli N. Cimetidine prevents recurrent erythema multiforme major resulting from herpes simplex virus infection. J Am Acad Dermatol. Oct 1989;21(4 Pt 1):814-5. [Medline].

  33. Brice SL. Erythema multiforme. In: Weston WL, ed. Current Problem in Dermatology. Chicago: Year Book; 1990:4.

  34. Fritsh PO, Rui-Maldonado R. Erythema multiforme. In: Freedberg IM, et al, eds. Fitzpatrick's Dermatology in General Medicine. New York: McGraw-Hill; 1999:636-44.

  35. Huff JC, Weston WL. Recurrent erythema multiforme. Medicine (Baltimore). May 1989;68(3):133-40. [Medline].

  36. Huff JC, Weston WL, Tonnesen MG. Erythema multiforme: a critical review of characteristics, diagnostic criteria, and causes. J Am Acad Dermatol. Jun 1983;8(6):763-75. [Medline].

  37. Leenutaphong V, Sivayathorn A, Suthipinittharm P, Sunthonpalin P. Stevens-Johnson syndrome and toxic epidermal necrolysis in Thailand. Int J Dermatol. Jun 1993;32(6):428-31. [Medline].

  38. Leigh IM, Mowbray JF, Levene GM, Sutherland S. Recurrent and continuous erythema multiforme--a clinical and immunological study. Clin Exp Dermatol. Jan 1985;10(1):58-67. [Medline].

  39. Malnick SD, Green L. Erythema multiforme and herpes simplex virus. Lancet. Feb 3 1990;335(8684):302. [Medline].

  40. Rappersberger K, Foedinger D. Treatment of erythema multiforme, Stevens-Johnson syndrome and toxic epidermal necrolysis. Dermatol Ther. 2002;15(4):397-408.

  41. Roujeau JC. The spectrum of Stevens-Johnson syndrome and toxic epidermal necrolysis: a clinical classification. J Invest Dermatol. Jun 1994;102(6):28S-30S. [Medline].

  42. Schofield JK, Tatnall FM, Leigh IM. Recurrent erythema multiforme: clinical features and treatment in a large series of patients. Br J Dermatol. May 1993;128(5):542-5. [Medline].

  43. Weston W, Orchard D. Erythema multiforme, Stevens-Johnson syndrome, Toxic epidermal necrolysis. In: Schachner LA, Hansen RC, Happle R, Krafchik BR, Lucky AW, Paller AS, Rogers M, editors. Pediatric Dermatology. 3rd edition. Edinburgh: Mosby; 2003:809-14.

  44. Weston WL, Hogan PA. Erythema multiforme, Stevens-Johnson syndrome. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology. New York: Churchill Livingstone; 1995:924-9.

  45. Williams RE, Lever R. Very low dose acyclovir can be effective as prophylaxis for post-herpetic erythema multiforme. Br J Dermatol. Jan 1991;124(1):111. [Medline].

  46. Zohdi-Mofid M, Horn TD. Acrosyringeal concentration of necrotic keratinocytes in erythema multiforme: a clue to drug etiology. Clinicopathologic review of 29 cases. J Cutan Pathol. Apr 1997;24(4):235-40. [Medline].

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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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