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Erythema multiforme is a skin disorder that's considered to be an allergic reaction to medicine or an infection. Symptoms are symmetrical, red, raised skin areas that can appear all over the body. They do seem to be more noticeable on the fingers and toes. These patches often look like "targets" (dark circles with purple-grey centers). The skin condition may happen over and over again, and usually lasts for 2 to 4 weeks each time.
Most often, this disorder is caused by the herpes simplex virus. It has also been associated with Mycoplasma pnemoniae as well as fungal infections. Other causes may include the following:
An interaction with a certain medicine
Other infectious diseases
Certain vaccines
What are the symptoms of erythema multiforme?
The following are the most common symptoms of erythema multiforme:
Sudden, red patches and blisters, usually on the palms of hands, soles of feet, and face
Flat, round red "targets" (dark circles with purple-grey centers)
Itching
Cold sores
Fatigue
Joint pains
Fever
The symptoms of erythema multiforme may resemble other skin conditions. Always talk with your healthcare provider for a diagnosis.
Treatment for erythema multiforme
Specific treatment for erythema multiforme will be discussed with you by your healthcare provider based on:
Your age, overall health, and medical history
Severity of the condition
Stage of the condition
Your tolerance of specific medicines, procedures, or therapies
Expectations for the course of the condition
Your opinion or preference
Erythema multiforme minor is not very serious and usually clears up with medicine to control infection or inflammation. However, if a person develops a more severe form of erythema multiforme (erythema multiforme major), the condition can become fatal. Erythema multiforme major is also known as Stevens-Johnson syndrome. It is usually caused by a medicine reaction rather than an infection.
Treatment may include:
Hospitalization
Intravenous fluids
Treating the infectious disease causing the disorder
Eliminating any medicine causing the disorder
Cool compresses
Corticosteroids
Antibiotics
It is recommended that if you have symptoms of erythema multiforme, go to your emergency room or call 911. If a large area of skin is involved, it is an emergency situation.
Erythema multiforme is an inflammatory reaction, characterized by target or iris skin lesions. Oral mucosa may be involved. Diagnosis is clinical. Lesions spontaneously resolve but frequently recur. Erythema multiforme usually occurs as a reaction to an infectious agent such as herpes simplex virus or mycoplasma but may be a reaction to a drug. Suppressive antiviral therapy may be indicated for patients with frequent or symptomatic recurrence due to herpes simplex virus.
For years, erythema multiforme was thought to represent the milder end of a spectrum of drug hypersensitivity disorders that included Stevens-Johnson syndrome Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) Stevens-Johnson syndrome and toxic epidermal necrolysis are severe cutaneous hypersensitivity reactions. Drugs, especially sulfa drugs, antiseizure drugs, and antibiotics, are the most common... read more
Etiology of Erythema Multiforme
The majority of cases are caused by
Herpes simplex virus (HSV) infection Herpes Simplex Virus (HSV) Infections Herpes simplex viruses (human herpesviruses types 1 and 2) commonly cause recurrent infection affecting the skin, mouth, lips, eyes, and genitals. Common severe infections include encephalitis... read more
HSV-1 is more often a cause than HSV-2, although it is unclear whether erythema multiforme lesions represent a specific or nonspecific reaction to the virus. Current thinking holds that erythema multiforme is caused by a T-cell–mediated cytolytic reaction to HSV DNA fragments present in keratinocytes. A genetic disposition is presumed given that erythema multiforme is such a rare clinical manifestation of HSV infection, and several human leukocyte antigen subtypes have been linked with the predisposition to develop lesions.
Less commonly, cases are caused by drugs, vaccines, other bacterial or viral diseases (especially hepatitis C), or possibly systemic lupus erythematosus Systemic Lupus Erythematosus (SLE) Systemic lupus erythematosus is a chronic, multisystem, inflammatory disorder of autoimmune etiology, occurring predominantly in young women. Common manifestations may include arthralgias and... read more
Symptoms and Signs of Erythema Multiforme
Erythema multiforme manifests as the sudden onset of asymptomatic, erythematous macules, papules, wheals, vesicles, bullae, or a combination on the distal extremities (often including palms and soles) and face. The classic lesion is annular with a violaceous center and pink halo separated by a pale ring (target or iris lesion). Distribution is symmetric and centripetal, sometimes spreading to the trunk. Some patients have itching.
Manifestations of Erythema Multiforme
This image shows target lesions (sometimes called iris lesions). Such lesions, which are typical of erythema multiforme, can appear on the palms.
Image courtesy of Julia Benedetti, MD.
Erythema multiforme is characterized by target or iris lesions, which are annular lesions with a violaceous center and pink halo separated by a pale ring.
DR P. MARAZZI/SCIENCE PHOTO LIBRARY
This image shows characteristic target or iris lesions of erythema multiforme.
Image courtesy of Karen McKoy, MD.
Oral lesions include target lesions on the lips and vesicles and erosions on the palate and gingivae.
Diagnosis of Erythema Multiforme
Clinical evaluation
Diagnosis of erythema multiforme is by clinical appearance; biopsy is rarely necessary.
Differential diagnosis includes urticaria Urticaria Urticaria consists of migratory, well-circumscribed, erythematous, pruritic plaques on the skin. Urticaria also may be accompanied by angioedema, which results from mast cell and basophil activation... read more
Oral lesions must be distinguished from aphthous stomatitis Recurrent Aphthous Stomatitis Recurrent aphthous stomatitis (RAS) is a common condition in which round or ovoid painful ulcers recur on the oral mucosa. Etiology is unclear. Diagnosis is clinical. Treatment is symptomatic... read more
Patients with widely disseminated purpuric macules and blisters and prominent involvement of the trunk and face are likely to have Stevens-Johnson syndrome Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) Stevens-Johnson syndrome and toxic epidermal necrolysis are severe cutaneous hypersensitivity reactions. Drugs, especially sulfa drugs, antiseizure drugs, and antibiotics, are the most common... read more
Treatment of Erythema Multiforme
Supportive care
Sometimes prophylactic antivirals
Erythema multiforme spontaneously resolves, so treatment is usually unnecessary. Topical corticosteroids and anesthetics and oral antihistamines may ameliorate symptoms and reassure patients.
Recurrences are common, and empiric oral maintenance therapy with antiherpetic drugs such as acyclovir 400 mg orally every 12 hours, famciclovir 250 mg orally every 12 hours, or valacyclovir 1000 mg orally every 24 hours can be attempted if symptoms recur more than 5 times/year and HSV association is suspected or if recurrent erythema multiforme is consistently preceded by herpes flares.
Key Points
Erythema multiforme is usually triggered by herpes simplex virus (HSV) but can be caused by a drug.
Target lesions and lesions on the palms and soles can be relatively specific findings.
Biopsy is rarely necessary.
Treat erythema multiforme supportively and consider prophylactic antiviral drugs if HSV is the suspected cause and recurrences are frequent.