Medication Summary
Systemic corticosteroid therapy is controversial in erythema multiforme (EM), and some believe it may predispose to complications. If given, the course should be limited to 10 days to 2 weeks. Beneficial effects with hemodialysis, plasmapheresis, cyclosporin, immunoglobulin, levamisole, thalidomide, dapsone, apremilast, [30] adalimumab, [31] and cyclophosphamide have been documented in case reports.
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 herpes simplex virus (HSV) infection. In children, 10 mg/kg/d may be considered. [32, 33, 34] 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. [29]
Alternative treatments for erythema multiforme include dapsone, antimalarials, azathioprine, cimetidine, [35] and thalidomide.
For ocular involvement, artificial wetting solutions, antibiotic solutions, or ointments may be helpful.
Prophylactic antibiotics are not recommended because of the increased likelihood of selecting out resistant strains. However, prompt culturing should be obtained with evidence of infection and then appropriate selection of antimicrobial therapy based on culture and sensitivity results. Some authors recommend routine alternate-day skin biopsy for culture to distinguish simple skin colonization from true infectious invasion and to guide antimicrobial therapy.
Antivirals
Class Summary
The goal in the use of antivirals is to shorten the clinical course, prevent complications, prevent development of latency and/or subsequent recurrences, decrease transmission, and eliminate established latency.
Acyclovir (Zovirax)
Acyclovir reduces the duration of symptomatic erythema multiforme lesions (EM). Patients on acyclovir experience less pain and faster resolution of cutaneous lesions.
This agent is indicated for patients who present within 48 hours of experiencing the rash.
Acyclovir demonstrates inhibitory activity directed against both herpes simplex virus type 1 (HSV-1) and HSV-2; infected cells selectively take it up.
Valacyclovir (Valtrex)
Valacyclovir is a prodrug that is rapidly converted to the active drug acyclovir. It produces greater serum concentrations of acyclovir with smaller oral dosing. Consider using this agent if lesions are unresponsive to acyclovir.
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Target lesion of erythema multiforme.
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Raised atypical targets and arcuate lesions.
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Hemorrhagic crusts on the lips.
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Interface dermatitis with prominent dyskeratotic cells in epidermis.
