eMedicine Specialties > Emergency Medicine > Dermatology

Erythema Multiforme: Follow-up

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

Follow-up

Further Inpatient Care

  • Hospitalization for fluid and electrolyte management is indicated when severe mucous membrane involvement is present or with impaired oral intake, dehydration, or secondary infection.
  • Implement barrier isolation to decrease risk of infection.
  • IV antibiotics may be necessary to treat secondary infections.
  • Areas of denuded skin should be managed like thermal burns, although debridement is best avoided while lesions are still progressing.
  • Eroded areas may be bathed q1-2d with saline or Burrow's solution and dressed with nonadherent dressings.

Further Outpatient Care

  • Provide symptomatic relief.
  • Discontinue use of potentially contributing drugs.

Inpatient & Outpatient Medications

  • Avoid use of systemic corticosteroids in erythema multiforme (EM); their use is controversial in EMM and SJS/TEN.
  • Topical corticosteroids are useful for outpatient treatment of patients with limited disease.
  • Prophylactic oral acyclovir is effective in decreasing frequency and severity of recurrent herpes and herpes-associated EM.
    • Consider use when recurrences are more frequent than 5 per year.
    • Prophylaxis may be required for 6-12 months or longer.
    • If unresponsive, continuous therapy of valacyclovir 500 mg bid has been reported effective.
    • Case reports exist of alternative treatments with immunosuppressants such as azathioprine. No well-controlled trials exist to support the beneficial effects of immunosuppressive therapy.
  • Human intravenous immunoglobulin has been used in treatment of SJS/TEN. However, these studies were open and uncontrolled trials, which make it difficult to accept IVIG as a standard of therapy for SJS/TEN.
  • Alternative treatments of EM include dapsone, antimalarials, cimetidine, and thalidomide.

Transfer

  • Severe cases require treatment in an intensive care unit or burn unit.

Deterrence/Prevention

  • Avoid known or suspected predisposing medications.
  • Acyclovir may be helpful in reducing recurrence of EM caused by herpes.
  • Tamoxifen may prevent premenstrual EM.

Complications

  • Hypopigmentation or hyperpigmentation
  • Scarring
  • Dehydration and electrolyte disturbances
  • Secondary bacterial infections/sepsis
  • Ocular complications, including corneal ulceration, anterior uveitis, panophthalmitis, corneal opacities, symblepharon formation, and blindness
  • Esophageal, bronchial, urethral, vaginal, and anal strictures (rare)
  • Possible GI hemorrhage, renal failure, and respiratory failure in severe cases

Prognosis

  • Most cases of EM are self-limited, with lesions evolving over 1-2 weeks and subsequently resolving within 2-3 weeks. SJS/TEN may require 3-6 weeks to resolve.
  • Scarring is rare but may follow SJS/TEN and is more common after resolution of mucosal lesions. Patients who form keloids may be at higher risk.
  • Hypopigmentation or hyperpigmentation may follow resolution of lesions.
  • Recurrence is common in EM (up to one third of cases) but is not common in SJS/TEN.
  • SJS and TEN may have a fulminant course complicated by severe secondary infection, fluid and electrolyte imbalances, and death in 5% and 30% of cases, respectively.

Patient Education

  • Educate patients in appropriate symptomatic treatment.
  • Provide reassurance that disease is self-limited.
  • Advise of significant risk of recurrence, especially in EM.
  • Emphasize avoidance of any identified etiologic agent.
  • For excellent patient education resources, visit eMedicine's Skin, Hair, and Nails Center. Also, see eMedicine's patient education article Life-Threatening Skin Rashes.

Miscellaneous

Medicolegal Pitfalls

  • Failure to diagnose Stevens-Johnson syndrome early in the course may result in a premature discharge of the patient, with subsequent deterioration in patient's condition.
  • Patients and parents, when appropriate, should be warned about potential long-term complications.

Special Concerns

  • Pregnancy may contribute to development of EM.
  • EM is rare in children younger than 3 years.
  • EM is rare in persons older than 50 years.
  • EM is more common in younger males, while SJS/TEN occurs equally in the sexes with a predominance in older patients.
 


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.