eMedicine Specialties > Emergency Medicine > Dermatology

Erythema Multiforme: Differential Diagnoses & Workup

Author: Olufunmilayo Ogundele, MD, Clinical Assistant Instructor, Staff Physician, Departments of Emergency and Internal Medicine, State University of New York Downstate, Kings County Hospital Center
Coauthor(s): Mark A Silverberg, MD, FACEP, MMB, Assistant Professor, Assistant Residency Director, Department of Emergency Medicine, State University of New York Downstate College of Medicine; Consulting Staff, Department of Emergency Medicine, Staten Island University Hospital, Kings County Hospital, University Hospital, State University of New York Downstate at Brooklyn; James Foster, MD, MS, Consulting Staff, Department of Emergency Medicine, Palomar Pomerado Health
Contributor Information and Disclosures

Updated: Feb 24, 2009

Differential Diagnoses

Herpes Simplex
Pityriasis Rosea
Stevens-Johnson Syndrome
Urticaria

Other Problems to Be Considered

Behçet syndrome
Collagen vascular diseases
Dermatitis herpetiformis
Drug eruptions
Figurate erythema
Fixed drug eruption
Granuloma annulare
Herpes gestationis
Herpetic gingivostomatitis
Lichen planus
Meningococcemia
Mucocutaneous lymph node syndrome
Necrotizing vasculitis
Pemphigoid
Pemphigus vulgaris
Recurrent aphthous ulcers
Secondary syphilis
Septicemia
Serum sickness
Stevens-Johnson syndrome and toxic epidermal necrolysis
Urticaria
Viral exanthems

Workup

Laboratory Studies

  • No specific laboratory tests are indicated to make the diagnosis of erythema multiforme, which should be arrived at clinically.
  • Clinical picture can guide laboratory testing in severe cases.
    • CBC usually reveals moderate leukocytosis with atypical lymphocytes. Eosinophil count greater than 1000/mm3 may also be seen. Severely elevated total white blood cell counts indicate infection. Mild anemia may be present.
    • Electrolytes values may be abnormal with severe skin and mucous membrane involvement due to fluid losses. These values are useful to guide volume and electrolyte replacement therapy.
    • BUN and creatinine tests are indicated to screen for renal involvement and dehydration in severe cases requiring hospitalization.
    • Liver function tests may be abnormal with hepatic involvement.
    • The sedimentation rate may be elevated but is nonspecific.
  • Cultures are indicated in severe cases and should be obtained from blood, sputum, and mucosal lesions.
  • HSV antigens can be detected in keratinocytes by immunofluorescence.
  • HSV DNA has been detected primarily within keratinocytes by polymerase chain reaction.

Imaging Studies

  • No specific imaging studies are necessary in most cases.
  • Chest x-ray may be useful in cases with respiratory symptoms or signs, particularly if an underlying pulmonary infection is suspected.

Procedures

  • Skin biopsy may be performed in equivocal cases, particularly in absence of target lesions.
  • Pathological findings include a predominantly inflammatory pattern characterized by high density lichenoid infiltrate rich in T cells, and epidermal necrosis of the basal layer.

More on Erythema Multiforme

Overview: Erythema Multiforme
Differential Diagnoses & Workup: Erythema Multiforme
Treatment & Medication: Erythema Multiforme
Follow-up: Erythema Multiforme
Multimedia: Erythema Multiforme
References
[ CLOSE WINDOW ]

References

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

  2. Assier H, Bastuji-Garin S, Revuz J. 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].

  3. Auquier-Dunant A, Mockenhaupt M, Naldi L, Correia O, Schroder W, Roujeau JC. Correlations between clinical patterns and causes of erythema multiforme majus, Stevens-Johnson syndrome, and toxic epidermal necrolysis: results of an international prospective study. Arch Dermatol. Aug 2002;138(8):1019-24. [Medline].

  4. Chapel TA, Chapel J. Erythema multiforme. In: Tintinalli J, et al, eds. Emergency Medicine: A Comprehensive Study Guide. 4th ed. McGraw Hill Text; 1996:1114-1116.

  5. Dore J, Salisbury RE. Morbidity and mortality of mucocutaneous diseases in the pediatric population at a tertiary care center. J Burn Care Res. Nov-Dec 2007;28(6):865-70. [Medline].

  6. Forman R, Koren G, Shear NH. Erythema multiforme, Stevens-Johnson syndrome and toxic epidermal necrolysis in children: a review of 10 years' experience. Drug Saf. 2002;25(13):965-72. [Medline].

  7. Fritsch PO, Elias PM. Erythema multiforme and toxic epidermal necrolysis. In: Fitzpatrick TB, et al, eds. Dermatology in General Medicine. 4th ed. McGraw-Hill Professional Publishing; 1993:585-600.

  8. Hazin R, Ibrahimi OA, Hazin MI, Kimyai-Asadi A. Stevens-Johnson syndrome: pathogenesis, diagnosis, and management. Ann Med. 2008;40(2):129-38. [Medline].

  9. 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].

  10. Katta R. Taking aim at erythema multiforme. How to spot target lesions and less typical presentations. Postgrad Med. Jan 2000;107(1):87-90. [Medline].

  11. Le Duc M, King MS. Erythema multiforme. In: Dambro M, ed. Griffith's 5 Minute Clinical Consult. Lippincott Williams & Wilkins; 1997:376-377.

  12. Leaute-Labreze C, Lamireau T, Chawki D. Diagnosis, classification, and management of erythema multiforme and Stevens-Johnson syndrome. Arch Dis Child. Oct 2000;83(4):347-52. [Medline].

  13. Martinez AE, Atherton DJ. High-dose systemic corticosteroids can arrest recurrences of severe mucocutaneous erythema multiforme. Pediatr Dermatol. Mar-Apr 2000;17(2):87-90. [Medline].

  14. Paquet P, Pierard GE. Erythema multiforme and toxic epidermal necrolysis: a comparative study. Am J Dermatopathol. Apr 1997;19(2):127-32. [Medline].

  15. Power WJ, Ghoraishi M, Merayo-Lloves J. Analysis of the acute ophthalmic manifestations of the erythema multiforme/Stevens-Johnson syndrome/toxic epidermal necrolysis disease spectrum. Ophthalmology. Nov 1995;102(11):1669-76. [Medline].

  16. 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].

  17. 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].

  18. Roujeau JC, Stern RS. Severe adverse cutaneous reactions to drugs. N Engl J Med. Nov 10 1994;331(19):1272-85. [Medline].

  19. Simmons HM. Vesiculobullous eruptions. In: Schwartz GR, et al, eds. Principles and Practice of Emergency Medicine. 3rd ed. Williams & Wilkins; 1992:2315-2320.

  20. Stampien TM, Schwartz RA. Erythema multiforme. Am Fam Physician. Oct 1992;46(4):1171-6. [Medline].

  21. Stern RS. Improving the outcome of patients with toxic epidermal necrolysis and Stevens-Johnson syndrome. Arch Dermatol. Mar 2000;136(3):410-1. [Medline].

  22. 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].

  23. Villiger RM, von Vigier RO, Ramelli GP, et al. Precipitants in 42 cases of erythema multiforme. Eur J Pediatr. Nov 1999;158(11):929-32. [Medline].

  24. Williams PM, Conklin RJ. Erythema multiforme: a review and contrast from Stevens-Johnson syndrome/toxic epidermal necrolysis. Dent Clin North Am. Jan 2005;49(1):67-76, viii. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

erythema multiforme, erythema multiforme major, erythema multiforme minor, EM major, EM minor, Stevens-Johnson syndrome, acute mucocutaneous hypersensitivity reaction, skin eruption, toxic epidermal necrolysis, TEN, centripetal spread, vesiculobullous lesions, herpessimplex infection, Mycoplasma pneumoniae, drug eruptions

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Olufunmilayo Ogundele, MD, Clinical Assistant Instructor, Staff Physician, Departments of Emergency and Internal Medicine, State University of New York Downstate, Kings County Hospital Center
Olufunmilayo Ogundele, MD is a member of the following medical societies: American Medical Association and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Mark A Silverberg, MD, FACEP, MMB, Assistant Professor, Assistant Residency Director, Department of Emergency Medicine, State University of New York Downstate College of Medicine; Consulting Staff, Department of Emergency Medicine, Staten Island University Hospital, Kings County Hospital, University Hospital, State University of New York Downstate at Brooklyn
Mark A Silverberg, MD, FACEP, MMB is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

James Foster, MD, MS, Consulting Staff, Department of Emergency Medicine, Palomar Pomerado Health
James Foster, MD, MS is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Medical Editor

Debra Slapper, MD, Consulting Staff, Department of Emergency Medicine, St Anthony's Hospital
Debra Slapper, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Mark W Fourre, MD, Program Director, Department of Emergency Medicine, Maine Medical Center; Associate Clinical Professor, Department of Surgery, University of Vermont School of Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Steven C Dronen, MD, FAAEM, Director of Emergency Services, Director of Chest Pain Center, Department of Emergency Medicine, Ft Sanders Sevier Medical Center
Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.