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Chapter 29: Erythema Multiforme (Minus or Majus)

Maja Mockenhaupt

ERYTHEMA MULTIFORME (MINUS OR MAJUS)

Therapeutic Approach

Erythema multiforme (EM) is an acute mucocutaneous syndrome originally described by von Hebra in 1860 as erythema exudativum multiforme. The condition is infrequent and the course is usually mild and self-limited but carries a risk of relapse. Based on the degree of mucous membrane involvement, EM is separated into EM minus (EMm) if only skin and lips are involved, and EM majus (EMM) when mucous membranes are affected. EMM differs from Stevens-Johnson syndrome and is further differentiated in typical EMM with targets in mainly acral distribution, which is often caused by herpes simplex eruptions, and atypical EMM with target lesions in widespread distribution, which is frequently induced by mycoplasma pneumoniae. Respiratory infections of other (partly unknown) origin may also trigger EM. Therapy includes supportive care and topical and anti-infective treatments. Sometimes immunomodulating therapy is used.1-4 See Table 29-1.

Table 29-1Erythema Multiforme Treatment Table
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Table 29-1 Erythema Multiforme Treatment Table
MEDICATION NAME INDICATION MECHANISM OF ACTION DOSING ADVERSE EFFECTS SUGGESTED MONITORING LEVEL OF EVIDENCE (REFERENCE)
Supportive Care
Fluids, albumin, glucose Hypovolemia Fluid replacement for maintaining hemodynamic equilibrium; preferably via peripheral venous lines Depending on capacity to drink, when oral/pharyngeal mucosa is affected Edema, if too much volume Needed IV, III1,5
Electrolytes Electrolyte imbalance Correction of electrolyte imbalance As needed and recommended by protocols None, if monitored through daily blood checks and adjusted Needed IV, III1,5
Nutrition Calorie loss Promotion of healing; sometimes needed in children Nutritional support via nasogastric tube, when oral/pharyngeal mucosa is affected None, if monitored daily (blood sugar, albumin in peripheral blood, weight, if possible) and adjusted Needed IV, III1,5
Morphine derivates, eg, buprenorphine Pain Relief and prevention of pain, eg, before skin care Morphine is indicated, if VAS score is ≥4/10 Nausea, dizziness, addiction if used long-term Needed IV, III1,5
Topical Therapy of the Skin
Octenidine, lavanide, silver nitrate, chlorhexidine solution Superinfection of the skin Disinfection of the skin (erosive areas) May be warmed before application for patient comfort Rarely contact allergy   IV, III1,5
Nonadhesive, nonmedicated gauze dressings Denuded skin Avoidance of adhesion to clothes and sheets, enhancement of reepithelialization Depending on the area of denuded skin None, when handled carefully   III1,5
Topical Therapy of the Mucosa
Eyes
Preservative-free emollients, antibiotic (eg, ofloxacine) or antiseptic and/or steroid (eg, prednisolone or dexamethasone) eye drops Inflammation and discharge Avoidance of erosions and synechia Several times per day, eg, every 2 h; alternating antiseptic and anti-inflammatory eye drops   Ophthalmology consultation at least every other day III, IIb 1,5,6, 7
Mouth
Antiseptic (eg, chlorhexidine without alcohol) and analgesic (eg, lidocain) solutions Erosions and hygiene Improvement of healing, reduction of pain and avoidance of superinfection Several times per day None ENT-specialist ...

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