Erythema multiforme can result from hypersensitivity reactions to various drugs or be associated with infections e. Patients usually have numerous lesions of variable appearance consisting of macules, papules, and vesicles. Erythema multiforme em is an acute mucocutaneous hypersensitivity reaction with a variety of etiologies. The center of these lesions may be vesicular, purpuric, or necrotic. It is the result of cell mediated immune reaction due to. Both hsv 1 and hsv 2 trigger the erythema multiforme lesions. The unilateral or segmental distribution suggests either dermatomal involvement.
Erythema multiforme em is an acute, selflimited skin condition that is considered to be a type iv hypersensitivity reaction associated with certain infections most commonly herpes simplex virus hsv, medications sulfa drugs, and other various triggers. Erythema multiforme is an acute, inflammatory skin condition. One of the most common predisposing factors for erythema multiforme is infection with herpes simplex virus. Skin lesions predominantly involving the extremities hands, feet, and mucosa. Erythema multiforme lesions are associated with expression of a herpes simplex virus hsv gene and qualitative alterations in the hsvspecific tcell response. The lesions may resemble urticaria early in the course of the disease. Erythema multiforme em refers to a group of hypersensitivity disorders characterized by symmetric red, patchy lesions, primarily on the arms and legs.
Large, symmetrical red blotches appear all over the skin in a circular. Erythema multiforme em is an immunemediated condition characterized by the appearance of targetlike lesions on the skin and often accompanied by erosions or bullae involving the oral, genital, andor ocular mucosae. Studies are reported on a patient with a sevenyear history of recurrent attacks of erythema multiforme. The target lesion exhibits central necrosis surrounded by a rim of perivenular inflammation mucosal involvement may include erythema, edema, sloughing, blistering, ulceration, and necrosis. Erythema multiforme syndrome associated with varicella nejm. This series alerts us to atypical forms of herpes simplex associated erythema multiforme, and points to a possible role of systemic steroids in exacerbating this condition. Erythema multiforme em is an acute, selflimited, inflammatory cutaneous disorder caused by infection or drugs that is characterized by bulls eye lesions, blisters, and erythematous plaques on the skin fitzpatrick and bernhard 1987. Erythema multiforme is associated with an acute onset. In these cases, recurrent episodes of erythema multiforme are usually related to hsv infection. This reaction causes red, targetshaped or bullseye patches or sores on the skin. Direct fluorescent antigen testing of these herpetic lesions confirmed hsv infection, and a punch biopsy of the target lesion demonstrated interface dermatitis consistent with erythema multiforme. Varicella zoster virus vzv has rarely been reported as an etiological agent, despite its high incidence as a pathogen in childhood. Herpes associated erythema multiforme listed as haem. Longterm valacyclovir treatment and immune modulation for.
Erythema multiforme is an acute inflammatory skin disease where 90% of the minor cases follow outbreaks of herpes simplex. Herpes associated erythema multiformea diagnostic dilemma. Acyclovir, azathioprine, corticosteroid side effects case report introduction recurrent erythema multiforme em is a disabling. Erythema multiforme is usually a reaction of the skin and mucous membranes that occurs suddenly. Herpes associated erythema multiforme how is herpes associated erythema multiforme abbreviated. Eight cases of erythema multiforme em have been reported to the us food and drug administration fda in temporal association with inoculation with the hepatitis b vaccine. Herpes simplex virus hsv associated erythema multiforme haem. Pdf herpes associated erythema multiforme researchgate. Erythema multiforme is a hypersensitivity reaction to an infection or, in some cases, a medicine. Acute hiv infection presenting as erythema multiforme in a. The rash usually starts off looking like pink or red blotches that develop over a few days into round shapes that look like targets with red, pink, and pale rings. Clinical and laboratory studies complement deposition in the skin of patients with herpes associated erythema multiforme ronald grimwood, major, mc, usa, j. It is estimated that 2040% of cases of erythema multiforme are secondary to herpes simplex virus infection.
Erythema multiforme an overview sciencedirect topics. We describe a 76year old immunocompetent male patient with thoracic herpes zoster. Erythema multiforme most commonly affects young adults 2040 years of age, however all age groups can be affected. It presents with a skin eruption characterised by a typical target lesion. The unilateral or segmental distribution suggests either dermatomal involvement or a mosaic expression of increased susceptibility. Herpesassociated erythema multiforme dermatology jama. Classified as erythema multiforme minor or erythema. Medicinenet does not provide medical advice, diagnosis or treatment. Some of the common signs and symptoms associated with erythema multiforme are listed below. Erythema multiforme is a hypersensitivity reaction usually triggered by infections, most commonly herpes simplex virus hsv. Erythema multiforme as first sign of incomplete kawasaki.
Herpes simplex virusassociated recurrent erythema multiforme. Erythema multiforme em is an acute, selflimited skin condition. Erythema multiforme major this is the form that is more severe. It is an eruption of classic target lesions on the extremities associated with. Erythema multiforme syndrome has been known to have a number of possible causes, including infectious agents and drugs. Erythema multiforme is an acute, selflimited, and sometimes recurring skin condition considered to be a hypersensitivity reaction associated with certain infections and medications table 11,2. Acute hiv infection presenting as erythema multiforme in a 45. Here we report a case of herpes simplex virusassociated recurrent erythema multiforme. Erythema multiforme is a rare disorder that affects slightly more males than females. Herpes associated erythema multiforme haem is an acute exudative dermatic and mucosal disease caused by the infecting herpes simplex virus. Association between hsv infection and em has been designated haemherpes associated erythema multiforme.
Pdf pherpes associated erythema multiforme haem is an acute exudative dermatic and mucosal disease caused by the herpes simplex. Detection of herpes simplex virus dna in cutaneous lesions of. We report a case of recurrent herpesassociated erythema multiforme managed with prophylactic acyclovir. It is now separated from stevens johnson syndrome sjs and toxic epidermal necrolysis t. The small observed risk of em is outweighed by the benefits of hepatitis b prevention. Erythema multiforme mainly affects adults under 40. Erythema multiforme em is a skin condition of unknown cause. Outcomesresolutions most erythema multiforme minor skin lesions often resolve in about 26 weeks. Doctors can determine the stage of lesion formation only after a complete examination of the skin. Erythema multiforme pictures, treatment, causes, symptom. Theres also a rare, severe form that can affect the mouth, genitals and eyes and can be lifethreatening. An 11yearold boy had lesions in the oral cavity and. Feb 20, 2020 erythema multiforme em is an acute, selflimited, and sometimes recurring skin condition that is considered to be a type iv hypersensitivity reaction associated with certain infections, medications, and other various triggers. Varicellalike lesions have been reported as part of the syndr.
Since the licensing of hepatitis b vaccine in 1982, the fda, in collaboration with the vaccine manufacturer and the. Em and the side effects associated with years of chronic highdose steroid usage. Varicella zoster virus infection associated with erythema. Erythema multiforme em is conventionally separated into em minor and em major. The rash that is associated with erythema multiforme will usually develop quickly and could be the only symptom that a person has with this medical condition. Erythema multiforme causes, symptoms, treatment, pictures. Previous studies have suggested, but not definitively demonstrated, the presence ofhsv in lesions of haem.
Erythema multiforme is a severe, treatable allergic skin. The implication of mhc class molecules on susceptibility yuchi chen chunghsing chang erythema multiforme is an acute mucocutaneous hypersensitivity reaction caused by a variety of etiologies. It is characterized by skin eruptions, with or without oral or other mucus membrane lesions. Etiopathogenesis of erythema multiforme juniper publishers. Erythema multiforme is caused by a cellmediated immune response, and infections are associated with 90% of cases. Herpes simplex virus hsvassociated erythema multiforme.
Despite multiple associations, thought to be triggered by hsv in most cases. Intradermal skin tests with a formaldehyde inactivated herpes simplex antigen. Complement deposition in the skin of patients with herpes. The cause is unknown, but em frequently occurs in association with herpes simplex virus, suggesting an immunologic process initiated by the virus. In the absence of classical presentation, the laboratoristic evaluation of systemic inflammation can help in placing the correct diagnosis to promptly start adequate therapy. In each instance, herpes simplex of the face preceded the generalized vesiculobullous eruption by seven to ten days. Herpesassociated erythema multiforme how is herpes.
Erythema multiforme introduction and epidemiology erythema multiforme em is an acute, immunemediated condition, most commonly induced by herpes simplex virus hsv infection, or by the use of medications, such as phenytoin, sulfonamides, penicillins, and barbiturates. Which viral infections cause erythema multiforme em. Usually, the diagnosis can be made on the basis of the size, shape, color and distribution of the target lesions. The spots enlarge and become irregularly shaped plaques. Herpesassociated erythema multiforme how is herpesassociated erythema multiforme abbreviated. Association between hsv infection and em has been designated haem herpes associated erythema multiforme. May 02, 2020 aydogan k, karadogan s, balaban adim s, tunali s. It appears as a symmetrical rash and may include the mucous membrane lesions. This series alerts us to atypical forms of herpes simplexassociated erythema multiforme, and points to a possible role of systemic steroids in exacerbating this condition. Erythema multiforme is an allergic reaction with many different causes. Definition erythema multiforme is a skin disease that causes lesions and redness around the lesions. Incomplete kawasaki disease represents a diagnostic challenge for pediatricians.
Detection of herpes simplex virus dna in cutaneous lesions. The incidence of em has been estimated to be between 0. One of the most intriguing discoveries of the past 20 y is the finding that herpes simplex virus hsv is responsible for precipitating most of the erythema multiforme em episodes in adults and children brice et al, 1989xbrice et al. However, these may return or recur in over 30% of the individuals. Denver, co granular staining for c3 by direct immunofluorescence is a frequent finding along the dermoepidermal junction and in papillary blood vessels in the early skin lesions of erythema. Management of erythema multiforme associated with recurrent. Herpes simplex virus as a cause of erythema multiforme jama. Erythema multiforme may be present within a wide spectrum of severity. Herpesassociated erythema multiforme listed as haem. Not all cases of erythema multiforme em can be prevented, especially if the offending agent is not apparent or remains unknown. Herpes simplex virus as a cause of erythema multiforme. Erythema multiforme em is an acute, selflimited, and sometimes recurring skin condition that is considered to be a type iv hypersensitivity reaction associated with certain infections, medications, and other various triggers. Peak incidence in second and third decades of life.
It is acute and selflimiting, usually resolving without complications. Description erythema multiforme appears on the skin and the mucous membranes the lining of the mouth, digestive tract, vagina, and other organs. It may begin at any age, but is most common in children and young adults. Multiforme refers to the lesions in the condition having various shapes. An outbreak starts with a reddish macule that turns into a papule. This is a condition that is caused by an allergic reaction to medications or an inflammatory reaction to viruses and fungi. Erythema multiforme is a skin reaction that can be triggered by an infection or some medicines. It is regarded as a hypersensitivity disorder which is triggered by multiple factors such as infection, drugs and food. This means that the body is sensitive to something that causes the skin and mucous membranes to react. Clinical and laboratory studies complement deposition in the skin of patients with herpesassociated erythema multiforme ronald grimwood, major, mc, usa, j. Erythema multiforme definition of erythema multiforme by. Erythema multiforme nord national organization for rare. Infections are probably associated with at least 90% of cases of erythema multiforme the single most common trigger for developing erythema multiforme is herpes simplex virus hsv infection, usually herpes labialis cold sore on the lip and less often genital herpes. Erythema multiforme is not indicative of a contagious disease and must not be mistaken as a sign of measles and other viral exanthems.
Erythema multiforme and hepatitis b immunization jama. Em is more common in men than women and 50% are under 20 years of age. No, erythema multiforme itself is not a contagious disease. Recently, erythema multiforme has been classified as minor, major, stevensjohnson syndrome or toxic epidermal necrolysis, where erythema multiforme minor is the mildest type of lesion and toxic epidermal necrolysis the most severe2,3 table 1. Weston university of colorado school ofmedicine, denver, colorado, usa one of the most intriguing discoveries of the past 20 y is the. Erythema multiforme pictures, treatment, symptoms, causes. We discuss the therapeutic options to aid physicians in treating this disabling condition. Erythema multiforme is an acute, selflimiting condition considered to be a hypersensitivity reaction commonly associated with various. Erythema multiforme after resolution of herpes zoster by acyclovir.
Lupus erythematosus associated with erythema multiforme. A diagnosis of herpesassociated erythema multiforme haem was made and the patient improved with a course of valacyclovir treatment. Herpes simplex virus associated erythema multiforme in prepubertal children. Picture of skin diseases and problems erythema multiforme. Acute human immunodeficiency virus infection presenting with erythema multiforme. Skin lesions may form in less than 24 hours after the development of erythema multiforme. In half of the cases, the triggering agents appear to be medications, including anticonvulsants. Dec 01, 2006 erythema multiforme is an acute, selflimited, and sometimes recurring skin condition considered to be a hypersensitivity reaction associated with certain infections and medications table 1 1, 2. Erythema multiforme is a cutaneous reaction that has only rarely been described in varicella zoster virus infection. The condition often starts as a red rash on the palms, soles, and back of the hands. Em minor, a mild allergic reaction, occurs most commonly. It can affect people of all ages and is often more severe in children and young adults. Hsv type 1 is more commonly associated than type 2.