Materiały źródłowe

• #1 Erythema Multiforme – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK470259/

  Erythema multiforme is an immune-mediated hypersensitivity reaction affecting both the skin and mucous membranes, characterized by the appearance of macular, papular, or bullous lesions that often form distinct „target lesions,” primarily found on the extremities. […] Erythema multiforme is a self-limiting condition that usually resolves without significant complications; however, a limited number of cases become persistent. Treatment focuses on managing symptoms and preventing recurrence, often through antiviral therapy for recurrent herpes-related cases. […] The diagnosis of erythema multiforme is based on history and clinical examination. Certain investigations, including skin biopsy, may help establish the diagnosis in cases with clinical diagnostic uncertainty. […] A punch biopsy can confirm the diagnosis of erythema multiforme. However, findings may vary slightly based on the site of the biopsy.

• #1 Erythema Multiforme: Recognition and Management | AAFP

  https://www.aafp.org/pubs/afp/issues/2019/0715/p82.html

  Erythema multiforme is diagnosed clinically, based on the patient’s history and physical examination. It is important to ask about recent symptoms of infection (e.g., HSV, M. pneumoniae) and medication use. Most cases of erythema multiforme do not require further diagnostic tests. However, in unclear cases, skin biopsies and laboratory tests may be helpful in excluding other diagnoses. The results of skin biopsies vary based on the timeline of the lesion and the location of the biopsy within the lesion. Direct immunofluorescence can help differentiate between erythema multiforme and autoimmune blistering diseases, such as bullous pemphigoid. […] The differential diagnosis includes many conditions, such as pityriasis rosea, urticaria, viral exanthema, fixed drug eruption, bullous pemphigoid, SJS, polymorphous light eruption, paraneoplastic pemphigus, and hypersensitivity reactions. Urticaria symptoms resemble erythema multiforme, and these two conditions should be distinguished based on the presentation of the lesions. Erythema multiforme typically has fixed lesions for a minimum of seven days, and individual urticarial lesions often resolve within one day. Fixed drug eruption usually has fewer lesions than erythema multiforme and a medication change is usually present in the patient’s history. Mucosal lesions associated with SJS may resemble erythema multiforme’s mucosal lesions, but can be differentiated by the lesion patterns on the skin. Although SJS usually contains widespread erythematous or purpuric macules with blisters, erythema multiforme manifests as papular, often target-shaped lesions. Patients with SJS should receive urgent medical attention because of the risk of complications.

• #1 Erythema multiforme – Symptoms, diagnosis and treatment | BMJ Best Practice

  https://bestpractice.bmj.com/topics/en-us/367

  Erythema multiforme is typically a mild, self-limiting, potentially recurring mucocutaneous inflammatory condition. […] Erythema multiforme (EM) is typically an acute, self-limiting but often relapsing, mucocutaneous inflammatory condition. It is a hypersensitivity reaction associated with certain infections, vaccinations, and, less commonly, medications. […] The disease is characterised clinically by target lesions, which can be described as annular erythematous rings with an outer erythematous zone and central blister sandwiching a zone of normal skin tone. […] In general, the lesions cover 10% of the total body surface area. […] Key diagnostic factors include presence of risk factors, target lesions of the extremities, previous episode of EM, and mucosal erosions. […] Other diagnostic factors include targetoid lesions, rapid onset of lesions, self-limiting course, clustered vesicles on an erythematous base, rhonchi, rales, and/or wheezes, and red tympanic membranes.

• #1 Erythema Multiforme in Children — Pediatric EM Morsels

  https://pedemmorsels.com/erythema-multiforme-children/

  Erythema multiforme is the skin manifestations of an acute immune-mediated reaction. […] Erythema multiforme is typically self-limited. […] Erythema multiforme in children is often misdiagnosed. […] Target lesions are NOT pathognomonic for erythema multiforme. […] The classification criteria for EM are based on Bastuji-Garin, 1993. […] When observing lesions, consider location and document what you see dont just say target lesions make note of all characteristics when able. […] EM Minor includes epidermal detachment 10% BSA, acrally distributed lesions, and no mucosal involvement. […] EM Major is the same as EM minor but has one or more mucosal surface involved. […] SJS and TEN lesions are different: flat, atypical target lesions or widespread macules. […] The amount of epidermal detachment determines classification.

• #1 Erythema Multiforme Differential Diagnoses

  https://emedicine.medscape.com/article/1122915-differential

  Although erythema multiforme (EM) is uncommon, the potentially life-threatening nature of the major form of the illness requires that clinicians maintain a high index of clinical awareness. Early diagnosis and aggressive supportive care are the essential elements of care in such severe cases. […] Any suspected EM adverse drug reactions should be reported to the manufacturer and the appropriate regulatory authorities. Only in this manner can problematic drugs be identified, relabeled, or possibly even withdrawn from the market. […] Conditions that should be considered in evaluating a patient with suspected EM include the following: Herpes simplex virus (HSV) infection, M pneumoniae infection, Acute generalized exanthematous pustulosis, Chemical burns, thermal burns, Collagen vascular diseases, Disseminated lesions of contact dermatitis, exfoliative dermatitis, Erythroderma, Figurate erythema, Granuloma annulare, Immunoglobulin A (IgA) linear dermatosis, Lichen planus, Lupus erythematosus, Lyme disease, Major oral aphthae, recurrent aphthous ulcers, Meningococcemia, Mucocutaneous lymph node syndrome, Necrotizing vasculitis, Pityriasis rosea, Secondary syphilis, Bloodstream infection (BSI), Serum sickness, Urticaria, Viral exanthems.

• #1 Erythema Multiforme – Dermatologic Disorders – Merck Manual Professional Edition

  https://www.merckmanuals.com/professional/dermatologic-disorders/hypersensitivity-and-reactive-skin-disorders/erythema-multiforme

  Erythema multiforme is an inflammatory reaction, characterized by target or iris skin lesions. […] Diagnosis is clinical. […] Diagnosis of erythema multiforme is by clinical appearance; biopsy is rarely necessary. […] Differential diagnosis includes urticaria, vasculitis, bullous pemphigoid, pemphigus, linear IgA dermatosis, acute febrile neutrophilic dermatosis, and dermatitis herpetiformis. […] Patients with widely disseminated purpuric macules and blisters and prominent involvement of the trunk and face are likely to have Stevens-Johnson syndrome rather than erythema multiforme. […] Biopsy is rarely necessary.

• #1 Erythema Multiforme Workup: Approach Considerations, Laboratory Studies, Procedures

  https://emedicine.medscape.com/article/1122915-workup

  No specific laboratory tests are indicated to make the diagnosis of erythema multiforme (EM), which should be arrived at clinically. The clinical picture can guide laboratory testing in severe cases. […] Cultures are indicated in severe cases and should be obtained from blood, sputum, and mucosal lesions. […] No specific imaging studies are necessary in most cases, although chest radiography may be useful in cases with respiratory symptoms or signs, particularly if an underlying pulmonary infection is suspected. […] The complete blood count (CBC) with differential usually reveals moderate leukocytosis with atypical lymphocytes and lymphopenia, possibly secondary to the depletion of CD4 lymphocytes (90% of patients). An eosinophil count higher than 1000/L may also be seen. Neutropenia (30% of patients) may occur and indicates a poor prognosis. A severely elevated total white blood cell (WBC) count indicates infection. Mild anemia may be present, and thrombocytopenia is found in 15% of patients.

• #1 Erythema Multiforme | AAFP

  https://www.aafp.org/pubs/afp/issues/2006/1201/p1883.html

  Erythema multiforme is diagnosed clinically. In patients who have target lesions with a preceding or coexisting HSV infection, the diagnosis can be made easily. Skin biopsy is not necessary when the clinical picture is clear because biopsy findings are not specific for erythema multiforme. In unclear cases, such as an atypical presentation or recurrent erythema multiforme without documented HSV infection, biopsy may help rule out other diagnoses. Laboratory tests (e.g., HSV-1 and -2, immunoglobulin M and G) may confirm a suspected history of HSV infection, but they are not required. […] Skin biopsy results vary depending on the clinical morphology and the duration of the lesions existence as well as the area of the lesion from which the specimen is obtained (i.e., the center portion or the outer zone). The early stage of the red macules and papules shows a perivascular mononuclear cell infiltrate. Biopsy of the edematous zone of the target lesion may show pronounced dermal edema histologically; necrotic keratinocytes or epidermal changes usually occur in the central portion of the target lesion.

• #1 Erythema Multiforme Workup: Approach Considerations, Laboratory Studies, Procedures

  https://emedicine.medscape.com/article/1122915-workup

  Blood urea nitrogen (BUN) and creatinine tests are indicated to screen for renal involvement and dehydration in severe cases necessitating hospitalization. Prerenal azotemia and elevated serum urea nitrogen levels may be found and indicate a poor prognosis. […] A cutaneous punch biopsy may be performed to allow histopathologic examination to confirm the diagnosis of EM and rule out alternative diagnoses (see Differentials). […] Histologically, erythema multiforme is the prototypical vacuolar interface dermatitis showing a lymphocytic infiltrate along the dermoepidermal junction associated with hydropic changes and dyskeratosis of basal keratinocytes. […] Histology and immunochemistry studies have shown that inflammatory infiltrates of EM and Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) are strikingly different in density and nature. EM has a high density of cell infiltrate rich in T lymphocytes. By contrast, SJS/TEN is characterized by a cell-poor infiltrate of macrophages and dendrocytes with strong tumor necrosis factor (TNF)- immunoreactivity.

• #1 Erythema multiforme – DermNet

  https://dermnetnz.org/topics/erythema-multiforme

  Diagnosis is often made based on history and clinical examination. […] Where there is doubt about the diagnosis, consider: Complete blood examination, Liver functions tests, ESR, Serological testing for infectious causes, Chest x-ray. […] Skin biopsy with histopathology and direct immunofluorescence can be non-specific but helps to distinguish erythema multiforme from other more serious differentials, such as autoimmune blistering diseases. Upper dermal oedema and individual epidermal keratinocyte necrosis are suggestive pathological features. […] All patients with recurrent erythema multiforme should be tested for herpes simplex virus, including sampling of skin or mucosal lesions. In recurrent or persistent erythema multiforme without a clear precipitant, consider work up for solid organ or haematological malignancies.

• #1 Diagnosis of Herpes Simplex Virus-Induced Erythema Multiforme Confounded by Previous Infection With Mycoplasma Pneumonia – JDDonline – Journal of Drugs in Dermatology

  https://jddonline.com/articles/diagnosis-of-herpes-simplex-virus-induced-erythema-multiforme-confounded-by-previous-infection-with-S1545961613P0707X/

  Erythema multiforme (EM) is an immune-mediated hypersensitivity reaction often related to viral infection or medications. […] We present a concise overview of diagnostic techniques for HSV and MP, as repeatedly elevated MP titers in our case led to a delayed diagnosis of HSV-induced EM. […] Herein, we present a concise overview of diagnostic techniques for HSV and MP, as repeatedly elevated MP titers with normal HSV IgM in our case led to a delayed diagnosis of HSV-induced EM. […] Serology can aid in the diagnosis of primary HSV infection, but is less helpful with distinguishing recurrences. […] HSV IgM becomes positive within 9 to 14 days of initial infection and remains elevated up to 7 weeks. […] However, IgM may not be produced during HSV recurrence, leading to missed diagnoses.

• #1 Clinical features, diagnosis, and treatment of erythema multiforme

  https://ostrowonline.usc.edu/clinical-features-diagnosis-and-treatment-of-erythema-multiforme/

  Erythema multiforme (EM): First described in 1866 by Ferdinand von Hebra as an acute, self-limited cutaneous disease characterized by multiform skin lesions, now called EM minor. […] In 1993 and 1995, Bastuji-Garin and colleagues proposed a new clinical classification for EM, SJS, and TEN supporting that SJS and TEN are distinct conditions from EM. […] Regardless of all these classifications efforts, in an analysis of 37 published cases of drug-induced EM, 24 case reports (65%) did not meet clinical criteria for EM. […] Clinical findings and course of the disease are usually enough to diagnose patients with EM. […] Diagnosis of EM Major would be appropriate in a patient with the following clinical features: A history of recent infection strongly suggests EM. […] EM mostly does not have skin detachment and, if present, is it below 10% of the BSA. […] EM is characterized by typical target-like or raised atypical targets lesions (described above). […] Finally, comparing to SJS/TEN, recurrences are more common with EM.

• #1 Erythema multiforme: Pathogenesis, clinical features, and diagnosis – UpToDate

  https://www.uptodate.com/contents/erythema-multiforme-pathogenesis-clinical-features-and-diagnosis

  Erythema multiforme (EM) is an acute, immune-mediated condition characterized by the appearance of distinctive target-like lesions on the skin. These lesions are often accompanied by erosions or bullae involving the oral, genital, and/or ocular mucosae. „Erythema multiforme major” is the term used to describe EM with severe mucosal involvement (and may have associated systemic symptoms, such as fever and arthralgias). Erythema multiforme minor refers to EM without (or with only mild) mucosal disease (and without associated systemic symptoms). […] The epidemiology, pathogenesis, clinical features, evaluation, and diagnosis of EM will be reviewed here. […] The term „erythema multiforme major” should not be used to refer to SJS. […] The clinical course of EM is usually self-limited, resolving within weeks without significant sequelae. However, in a minority of cases, the disease recurs frequently over the course of years. […] The diagnosis of EM includes history and physical examination and may involve biopsy.

• #1 ERYTHEMA MULTIFORME | Hand Surgery Resource

  https://www.handsurgeryresource.net/erythema-multi

  Erythema multiforme (EM) is an acute, immune-mediated, mucocutaneous condition characterized by round erythematous papules with concentric color changes that usually develop on the extremities. […] EM is typically classified as either minor or major: EM minor: typical lesions are symmetrical and have an acral disposition; mucosal involvement is rare, and when present, is light and affects a single mucosa, often the mouth […] EM major: skin lesions are more extensive; typical target lesions are present and mucosal involvement is severe, affecting at least two different mucosal sites, with the oral mucosa typically affected. […] No specific objective markers or criteria are required for an EM diagnosis, so patient history and clinical findings are important. […] Target lesions are often present and are considered diagnostic. To meet the criteria for a target lesion, three zones of color must be present: 1) a central dark area or blister surrounded by 2) a pale edematous zone surrounded by 3) a peripheral rim of erythema.

• #1 Erythema multiforme major/Stevens-Johnson syndrome: a diagnostic challenge | Anales de Pediatría

  https://www.analesdepediatria.org/en-erythema-multiforme-major-stevens-johnson-syndrome-diagnostic-articulo-S2341287924002643

  A male adolescent aged 14 years presented with fever, conjunctivitis, sore throat, oral ulcers, swollen lips and rash with onset 5 days prior. […] At this point, Stevens-Johnson syndrome (SJS) or erythema multiforme major (EMM) were suspected. […] The findings of the skin biopsy supported the diagnosis of SJS. […] Distinguishing between EMM and SJS is challenging. Both are characterized by widespread rash and mucous membrane involvement. However, EMM usually presents with typical target lesions mainly involving the skin, while SJS manifests with widespread erythematous macules and blisters, often leading to severe skin and mucous membrane detachment, with a higher risk of complications. […] Understanding these nuances is essential for accurate diagnosis and timely intervention.

• #1 Erythema Multiforme – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK470259/

  The treatment approaches of erythema multiforme can be divided into strategies for acute episodes and suppressing recurrent disease. […] The first step in managing erythema multiforme is to remove the underlying cause, eg, discontinuing the medication that could have triggered the reaction. […] In recurrent cases, the focus is on managing acute symptoms and eliminating the triggering factor to prevent future episodes. […] The effective management of erythema multiforme requires a coordinated, interprofessional approach to ensure optimal patient-centered care, safety, and outcomes.

• #2 Erythema multiforme: Pathogenesis, clinical features, and diagnosis – UpToDate

  https://www.uptodate.com/contents/erythema-multiforme-pathogenesis-clinical-features-and-diagnosis

  Erythema multiforme (EM) is an acute, immune-mediated condition characterized by the appearance of distinctive target-like lesions on the skin. These lesions are often accompanied by erosions or bullae involving the oral, genital, and/or ocular mucosae. „Erythema multiforme major” is the term used to describe EM with severe mucosal involvement (and may have associated systemic symptoms, such as fever and arthralgias). Erythema multiforme minor refers to EM without (or with only mild) mucosal disease (and without associated systemic symptoms). […] The epidemiology, pathogenesis, clinical features, evaluation, and diagnosis of EM will be reviewed here. […] The term „erythema multiforme major” should not be used to refer to SJS. […] The clinical course of EM is usually self-limited, resolving within weeks without significant sequelae. However, in a minority of cases, the disease recurs frequently over the course of years. […] The diagnosis of EM includes history and physical examination and may involve biopsy.

• #2 Erythema multiforme – DermNet

  https://dermnetnz.org/topics/erythema-multiforme

  Diagnosis is often made based on history and clinical examination. […] Where there is doubt about the diagnosis, consider: Complete blood examination, Liver functions tests, ESR, Serological testing for infectious causes, Chest x-ray. […] Skin biopsy with histopathology and direct immunofluorescence can be non-specific but helps to distinguish erythema multiforme from other more serious differentials, such as autoimmune blistering diseases. Upper dermal oedema and individual epidermal keratinocyte necrosis are suggestive pathological features. […] All patients with recurrent erythema multiforme should be tested for herpes simplex virus, including sampling of skin or mucosal lesions. In recurrent or persistent erythema multiforme without a clear precipitant, consider work up for solid organ or haematological malignancies.

• #2 Erythema multiforme

  https://www.nhs.uk/conditions/erythema-multiforme/

  It can sometimes be caused by some vaccines or medicines such as non-steroidal anti-inflammatory drugs (NSAIDs), antibiotics, statins and medicines for epilepsy. […] If it’s caused by a medicine, you usually need to stop taking it. But do not stop taking any medicines without talking to a doctor first.

• #2 Clinical features, diagnosis, and treatment of erythema multiforme

  https://ostrowonline.usc.edu/clinical-features-diagnosis-and-treatment-of-erythema-multiforme/

  Erythema multiforme (EM): First described in 1866 by Ferdinand von Hebra as an acute, self-limited cutaneous disease characterized by multiform skin lesions, now called EM minor. […] In 1993 and 1995, Bastuji-Garin and colleagues proposed a new clinical classification for EM, SJS, and TEN supporting that SJS and TEN are distinct conditions from EM. […] Regardless of all these classifications efforts, in an analysis of 37 published cases of drug-induced EM, 24 case reports (65%) did not meet clinical criteria for EM. […] Clinical findings and course of the disease are usually enough to diagnose patients with EM. […] Diagnosis of EM Major would be appropriate in a patient with the following clinical features: A history of recent infection strongly suggests EM. […] EM mostly does not have skin detachment and, if present, is it below 10% of the BSA. […] EM is characterized by typical target-like or raised atypical targets lesions (described above). […] Finally, comparing to SJS/TEN, recurrences are more common with EM.

• #2 Erythema Multiforme: Recognition and Management | AAFP

  https://www.aafp.org/pubs/afp/issues/2019/0715/p82.html

  Erythema multiforme is diagnosed clinically, based on the patient’s history and physical examination. It is important to ask about recent symptoms of infection (e.g., HSV, M. pneumoniae) and medication use. Most cases of erythema multiforme do not require further diagnostic tests. However, in unclear cases, skin biopsies and laboratory tests may be helpful in excluding other diagnoses. The results of skin biopsies vary based on the timeline of the lesion and the location of the biopsy within the lesion. Direct immunofluorescence can help differentiate between erythema multiforme and autoimmune blistering diseases, such as bullous pemphigoid. […] The differential diagnosis includes many conditions, such as pityriasis rosea, urticaria, viral exanthema, fixed drug eruption, bullous pemphigoid, SJS, polymorphous light eruption, paraneoplastic pemphigus, and hypersensitivity reactions. Urticaria symptoms resemble erythema multiforme, and these two conditions should be distinguished based on the presentation of the lesions. Erythema multiforme typically has fixed lesions for a minimum of seven days, and individual urticarial lesions often resolve within one day. Fixed drug eruption usually has fewer lesions than erythema multiforme and a medication change is usually present in the patient’s history. Mucosal lesions associated with SJS may resemble erythema multiforme’s mucosal lesions, but can be differentiated by the lesion patterns on the skin. Although SJS usually contains widespread erythematous or purpuric macules with blisters, erythema multiforme manifests as papular, often target-shaped lesions. Patients with SJS should receive urgent medical attention because of the risk of complications.

• #2 Erythema Multiforme | AAFP

  https://www.aafp.org/pubs/afp/issues/2006/1201/p1883.html

  The differential diagnosis of early erythema multiforme includes drug eruption, polymorphic light eruption, urticaria, urticarial vasculitis, viral exanthems, and other hypersensitivity reactions. Because erythema multiforme often resembles urticaria at the onset of the eruption, it is important to distinguish the clinical features. The individual lesions of erythema multiforme in typical cases are present and fixed for at least one week, and some evolve into target lesions. In contrast, the individual lesions of urticaria exist at the same site for less than 24 hours, and the centers of the lesions appear normal or as red as the borders.

• #2 Erythema Multiforme | Consultant360

  https://www.consultant360.com/articles/erythema-multiforme

  A 22-year-old African American woman noted 2 lesions on her lip that she thought were insect bites. […] She presented to an emergency department (ED) where she was diagnosed with herpes simplex virus (HSV) infection and was discharged with prescriptions for ibuprofen and cephalexin. […] A dermatologist was consulted to evaluate erythema multiforme (EM) versus Stevens-Johnson syndrome (SJS). […] The diagnosis of EM is based on the clinical history and clinical findings, with the use of skin biopsies and histopathology tests to help rule out imitators of EM. […] HSV infection testing can be done via Tzanck smear, polymerase chain reaction tests, or viral culture; however, HSV testing is not required for the diagnosis of EM.

• #2 Erythema multiforme – Symptoms, diagnosis and treatment | BMJ Best Practice

  https://bestpractice.bmj.com/topics/en-us/367

  1st investigations to order include clinical diagnosis. […] Investigations to consider include haematoxylin and eosin biopsy, immunofluorescence biopsy, FBC, serum electrolytes, herpes simplex virus (HSV) serology, rapid polymerase chain reaction (PCR), cold-haemagglutination serology, M pneumoniae titres, CXR, and auto-antibody titres. […] Emerging tests include anti-desmoplakin antibodies.

• #2 Erythema Multiforme: Treatment, Symptoms, and Causes

  https://www.webmd.com/skin-problems-and-treatments/erythema-multiforme

  Your doctor may suspect erythema multiforme when they examine you. But they may want to run some tests to know for sure. These may include: […] Blood tests. Your doctor may want to check your complete blood cell count. Signs of erythema multiforme include high levels of white blood cells and mild anemia. They may also check your erythrocyte sedimentation levels. Its a test to measure how fast your red blood cells sink to the bottom of a test tube. If its elevated, it could indicate erythema multiforme. […] Skin biopsy. Your doctor will look at your skin closely under a microscope to look for changes that are present if you have erythema multiforme. […] Chest X-ray. Theyll look for signs of a bacterial infection, such as pneumonia. […] Your doctor may also check for any potential triggers of erythema multiforme. This could include checking for skin lesions that could indicate a herpes simplex virus infection or symptoms such as a cough that might mean you have pneumonia.

• #2 Erythema Multiforme | AAFP

  https://www.aafp.org/pubs/afp/issues/2006/1201/p1883.html

  Erythema multiforme is diagnosed clinically. In patients who have target lesions with a preceding or coexisting HSV infection, the diagnosis can be made easily. Skin biopsy is not necessary when the clinical picture is clear because biopsy findings are not specific for erythema multiforme. In unclear cases, such as an atypical presentation or recurrent erythema multiforme without documented HSV infection, biopsy may help rule out other diagnoses. Laboratory tests (e.g., HSV-1 and -2, immunoglobulin M and G) may confirm a suspected history of HSV infection, but they are not required. […] Skin biopsy results vary depending on the clinical morphology and the duration of the lesions existence as well as the area of the lesion from which the specimen is obtained (i.e., the center portion or the outer zone). The early stage of the red macules and papules shows a perivascular mononuclear cell infiltrate. Biopsy of the edematous zone of the target lesion may show pronounced dermal edema histologically; necrotic keratinocytes or epidermal changes usually occur in the central portion of the target lesion.

• #2 Erythema Multiforme: Symptoms and Treatment | Doctor

  https://patient.info/doctor/erythema-multiforme-pro

  Diagnosing erythema multiforme (investigations) […] Usually, no specific investigations are indicated. […] Skin biopsy can be indicated in an atypical presentation or where there is recurrent EM without an obvious trigger. […] Investigations may be required to discover the underlying cause – eg, CXR, drug history, atypical pneumonia titres. […] An FBC will often show moderate leukocytosis, eosinophilia, neutropenia, mild anaemia, and thrombocytopenia. […] ESR may be elevated in severe cases. […] CXR may show interstitial disease if the underlying cause is Mycoplasma pneumoniae. […] If the diagnosis is unclear, a skin biopsy may be suggested.

• #2 Pathology Outlines – Erythema multiforme

  https://www.pathologyoutlines.com/topic/skinnontumorerythemamultiforme.html

  Acute, self limited, hypersensitivity reaction to infections (coccidioidomycosis, herpes simplex, histoplasmosis, leprosy, mycoplasma, typhoid), drugs (penicillin, phenylbutazone, phenytoin, salicylates, sulfa), carcinoma / lymphoma, or collagen vascular disorders […] Affects skin (distal extremities, palms, soles) and mucous membranes with target lesions […] Also sore throat and malaise […] Commonly recurs but rarely persists […] Variable (multiform) lesions, including papules, macules, vesicles, bullae, target lesions […] Commonly in mucous membranes; also elbows, knees, extensor surface of extremities […] Subepidermal bullae with basement membrane in bullae roof due to dermal edema […] Severe dermal inflammatory infiltrate (includes lymphocytes, histiocytes) […] Eosinophils may be present, but neutrophils are sparse or absent

• #2 Erythema multiforme: histological features and mechanisms

  https://dermnetnz.org/topics/erythema-multiforme-histological-features-and-mechanisms

  A skin biopsy of erythema multiforme (EM) may show in the epidermis/epithelium: […] Direct immunofluorescence is not specific. It may show deposition of immune proteins C3 and fibrin along the DEJ and IgM, C3 and fibrin around blood vessels. […] EM major can usually be distinguished from SJS/TEN on a number of clinical criteria. […] In the majority of cases, EM can be diagnosed as a distinct entity from SJS/TEN although there remain some patients in whom the distinction is not so clearcut.

• #2 Recent Updates in the Treatment of Erythema Multiforme

  https://www.mdpi.com/1648-9144/57/9/921

  Erythema multiforme (EM) is an immune-mediated condition that classically presents with discrete targetoid lesions and can involve both mucosal and cutaneous sites. […] While EM is typically preceded by viral infections, most notably herpes simplex virus (HSV), and certain medications, a large portion of cases are due to an unidentifiable cause. […] EM can be confused with other more serious conditions like Stevens–Johnson syndrome (SJS); however, clinical research has provided significant evidence to classify EM and SJS as separate disorders. […] Identifying the etiology of EM is crucial in developing a successful treatment modality. […] Most acute cases of EM have been reported to stem from infections caused by HSV and Mycoplasma pneumoniae. […] A Mayo Clinic series of 48 patients diagnosed with recurrent EM suggested that HSV infection was the most common cause; however, over 60% of patients were determined to have idiopathic recurrent EM.

• #2 Diagnosis of Herpes Simplex Virus-Induced Erythema Multiforme Confounded by Previous Infection With Mycoplasma Pneumonia – JDDonline – Journal of Drugs in Dermatology

  https://jddonline.com/articles/diagnosis-of-herpes-simplex-virus-induced-erythema-multiforme-confounded-by-previous-infection-with-S1545961613P0707X/

  HSV IgG becomes positive within 4 weeks and remains elevated indefinitely. […] HSV culture becomes positive within 2 to 5 days, but samples must be obtained from active vesicles during viral shedding, which lasts an average of 4 days. […] Cultures may be negative in over 50% of recurrent lesions, resulting in gross underdiagnoses. […] A comparison between DFA and viral culture found a sensitivity of 85% for DFA analysis. […] For recurrent lesions, multiple samples are recommended to maximize collection of viral particles. […] PCR detects DNA from ocular, oral and genital lesions, with superior specificity to culture.

• #2 Erythema Multiforme in Children — Pediatric EM Morsels

  https://pedemmorsels.com/erythema-multiforme-children/

  Erythema multiforme is the skin manifestations of an acute immune-mediated reaction. […] Erythema multiforme is typically self-limited. […] Erythema multiforme in children is often misdiagnosed. […] Target lesions are NOT pathognomonic for erythema multiforme. […] The classification criteria for EM are based on Bastuji-Garin, 1993. […] When observing lesions, consider location and document what you see dont just say target lesions make note of all characteristics when able. […] EM Minor includes epidermal detachment 10% BSA, acrally distributed lesions, and no mucosal involvement. […] EM Major is the same as EM minor but has one or more mucosal surface involved. […] SJS and TEN lesions are different: flat, atypical target lesions or widespread macules. […] The amount of epidermal detachment determines classification.

• #2 ERYTHEMA MULTIFORME | Hand Surgery Resource

  https://www.handsurgeryresource.net/erythema-multi

  Erythema multiforme (EM) is an acute, immune-mediated, mucocutaneous condition characterized by round erythematous papules with concentric color changes that usually develop on the extremities. […] EM is typically classified as either minor or major: EM minor: typical lesions are symmetrical and have an acral disposition; mucosal involvement is rare, and when present, is light and affects a single mucosa, often the mouth […] EM major: skin lesions are more extensive; typical target lesions are present and mucosal involvement is severe, affecting at least two different mucosal sites, with the oral mucosa typically affected. […] No specific objective markers or criteria are required for an EM diagnosis, so patient history and clinical findings are important. […] Target lesions are often present and are considered diagnostic. To meet the criteria for a target lesion, three zones of color must be present: 1) a central dark area or blister surrounded by 2) a pale edematous zone surrounded by 3) a peripheral rim of erythema.

• #2 Recent Updates in the Treatment of Erythema Multiforme

  https://www.mdpi.com/1648-9144/57/9/921

  A rarer type of EM is known as persistent EM, which is defined by the continuous appearance of EM lesions with marked resistance to therapy. […] Treatment modalities differ for acute and recurrent disease. […] In recurrent EM, treatment focuses on addressing the etiology through systemic antiviral prophylactic therapy. […] Current recommendations include acyclovir, 400 mg, twice daily, valacyclovir, 500 mg, twice daily, or famciclovir, 250 mg, twice daily. […] Continuous antiviral therapy is still a first-line therapy for recurrent EM, especially in HSV-induced EM. […] Treatment options must be carefully weighed, considering the various adverse effects that are possible with each therapy and their variable efficacies.

• #3 Erythema multiforme major/Stevens-Johnson syndrome: a diagnostic challenge | Anales de Pediatría

  https://www.analesdepediatria.org/en-erythema-multiforme-major-stevens-johnson-syndrome-diagnostic-articulo-S2341287924002643

  A male adolescent aged 14 years presented with fever, conjunctivitis, sore throat, oral ulcers, swollen lips and rash with onset 5 days prior. […] At this point, Stevens-Johnson syndrome (SJS) or erythema multiforme major (EMM) were suspected. […] The findings of the skin biopsy supported the diagnosis of SJS. […] Distinguishing between EMM and SJS is challenging. Both are characterized by widespread rash and mucous membrane involvement. However, EMM usually presents with typical target lesions mainly involving the skin, while SJS manifests with widespread erythematous macules and blisters, often leading to severe skin and mucous membrane detachment, with a higher risk of complications. […] Understanding these nuances is essential for accurate diagnosis and timely intervention.

• #3 Erythema Multiforme Versus Herpes Simplex Virus, What is the Diagnosis? A Review and a Case Report. – Biomedical and Pharmacology Journal

  https://biomedpharmajournal.org/vol12no4/erythema-multiforme-versus-herpes-simplex-virus-what-is-the-diagnosis-a-review-and-a-case-report/

  Erythema multiforme is a benign condition that spontaneously resolves with recurrence if the patient re expose to trigger factors. […] Estimation of EM patient is a challenge, there is no specific markers, objective criteria and no specific diagnostic investigation for EM diagnosis, although, there is raised white blood cell count and increased erythrocyte sedimentation rate value. Diagnosis of EM is usually based on comprehensive patient history and the clinical presentation. […] Diagnosis include the presence of targetoid lesions on the skin is confirming the diagnosis. […] Because EM is uncommon and many ulcerative oral lesions almost has similar presentation, the EM is usually miss diagnosed easily, its differential diagnosis should include the following: herpes simplex virus (HSV) infection, burns (thermal, chemical), mycoplasma pneumoniae infection, acute generalized exanthematous pustulosis, collagen vascular diseases, disseminated lesions of contact dermatitis, exfoliative dermatitis, erythroderma, igurate erythema, Granuloma annulare Immunoglobulin A (IgA) linear dermatosis, lichen planus, Lupus erythematosus, lyme disease, major oral aphthae, recurrent aphthous ulcers, meningococcemia, mucocutaneous lymph node syndrome, necrotizing vasculitis, pityriasis rosea, Secondary syphilis, septicemia, serum sickness, urticaria, viral exanthems.

• #3 Erythema Multiforme: Symptoms and Treatment | Doctor

  https://patient.info/doctor/erythema-multiforme-pro

  Diagnosing erythema multiforme (investigations) […] Usually, no specific investigations are indicated. […] Skin biopsy can be indicated in an atypical presentation or where there is recurrent EM without an obvious trigger. […] Investigations may be required to discover the underlying cause – eg, CXR, drug history, atypical pneumonia titres. […] An FBC will often show moderate leukocytosis, eosinophilia, neutropenia, mild anaemia, and thrombocytopenia. […] ESR may be elevated in severe cases. […] CXR may show interstitial disease if the underlying cause is Mycoplasma pneumoniae. […] If the diagnosis is unclear, a skin biopsy may be suggested.

• #3 Pathology Outlines – Erythema multiforme

  https://www.pathologyoutlines.com/topic/skinnontumorerythemamultiforme.html

  Overlying epidermis often demonstrates liquefactive necrosis and degeneration, dyskeratotic keratinocytes […] May also have dermoepidermal bullae with basal lamina at floor of bullae […] Variable epidermal spongiosis and eosinophils […] No leukocytoclasis, no microabscesses, no festooning of dermal papillae […] Note: erythema multiforme may have variable histologic changes from toxic epidermal necrolysis to dermal disturbances […] Acute graft versus host disease: clinical history; early changes are basal layer vacuolization and necrosis, spongiosis, apoptosis, acantholysis, chronic inflammation of upper dermis with perivascular lymphocytic infiltrate and intraepidermal lymphocytes […] Fixed drug reaction: eosinophils and marked vascular wall thickening […] Steven Johnson syndrome or toxic epidermal necrolysis: full thickness epidermal necrosis with separation of epidermis from dermis; necrotic keratinocytes at edge of bullae […] Subacute cutaneous lupus erythematosus: fibrinoid necrosis at dermoepidermal junction with liquefactive degeneration and atrophy of epidermis.

• #3 Erythema Multiforme – Dermatologic Disorders – Merck Manual Professional Edition

  https://www.merckmanuals.com/professional/dermatologic-disorders/hypersensitivity-and-reactive-skin-disorders/erythema-multiforme

  Erythema multiforme is an inflammatory reaction, characterized by target or iris skin lesions. […] Diagnosis is clinical. […] Diagnosis of erythema multiforme is by clinical appearance; biopsy is rarely necessary. […] Differential diagnosis includes urticaria, vasculitis, bullous pemphigoid, pemphigus, linear IgA dermatosis, acute febrile neutrophilic dermatosis, and dermatitis herpetiformis. […] Patients with widely disseminated purpuric macules and blisters and prominent involvement of the trunk and face are likely to have Stevens-Johnson syndrome rather than erythema multiforme. […] Biopsy is rarely necessary.

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