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Erythema multiforme

Erythema multiforme is an acute, immune-mediated hypersensitivity reaction that primarily affects the skin and sometimes the mucous membranes, characterized by the development of distinctive target-like or "bull's-eye" lesions that appear symmetrically on the extremities and can spread to the trunk.^[1] It typically presents as a self-limiting condition lasting 2 to 4 weeks, though severe cases may involve mucosal erosions and require medical intervention.^[2] The disorder is classified into minor and major forms, with the minor form limited to skin involvement and the major form featuring significant mucosal lesions affecting areas such as the mouth, eyes, or genitals.^[3] The most common triggers for erythema multiforme are infections, accounting for approximately 90% of cases, particularly herpes simplex virus (HSV) and Mycoplasma pneumoniae, while medications such as nonsteroidal anti-inflammatory drugs (NSAIDs), antibiotics, and anticonvulsants are implicated in fewer than 10% of instances.^[1] Less frequent causes include other infections like histoplasmosis or hepatitis C, autoimmune conditions, vaccinations, or underlying malignancies, though the exact mechanism involves a cell-mediated immune response leading to epidermal cell death.^[3] Genetic factors, such as associations with HLA-DQ3, may predispose certain individuals to recurrent episodes.^[1] Clinically, the condition often begins with a prodrome of fever, malaise, and sore throat 1 to 14 days after the trigger, followed by the eruption of erythematous macules or papules that evolve into raised, edematous target lesions measuring 1 to 3 cm in diameter, with a pale center, dark ring, and surrounding erythema.^[2] Symptoms include pruritus or burning at the lesion sites, and in major erythema multiforme, mucosal involvement occurs in 25% to 60% of cases, potentially leading to painful erosions that complicate eating, urination, or vision.^[3] The rash is typically fixed, persisting for at least 7 days.^[1] Epidemiologically, erythema multiforme affects individuals worldwide with an estimated annual incidence of less than 1%, predominantly young adults aged 20 to 40 years, though it occurs in 20% of pediatric cases, and is slightly more common in males (male-to-female ratio of approximately 2:1 to 3:1 in some studies).^[1]^[4] Diagnosis is primarily clinical, supported by skin biopsy showing vacuolar interface dermatitis and lymphocytic infiltration, and exclusion of mimics like Stevens-Johnson syndrome or urticaria through history and lesion morphology.^[3] Management focuses on removing the offending trigger, providing supportive care with topical corticosteroids, oral analgesics, and wound care, while antiviral prophylaxis such as acyclovir is recommended for HSV-associated recurrences, which occur in up to one-third of cases.^[2]^[4] The prognosis is excellent for minor forms, with full resolution without scarring, but major forms carry a mortality risk of less than 5% due to complications like secondary infections or dehydration.^[1]

Overview

Definition and Classification

Erythema multiforme is an acute, self-limited, immune-mediated type IV hypersensitivity reaction that primarily affects the skin and mucous membranes, manifesting as distinctive target-like lesions typically distributed on the extremities in an acral pattern.^[4]^[1] This condition arises as a reactive process, often triggered by infections or other stimuli, and is characterized by its polymorphous skin eruptions without widespread epidermal necrosis.^[4] The name "erythema multiforme" derives from the Greek "erythēma" (redness) and Latin "multiforme" (many forms), reflecting the varied morphology of its lesions, which can appear as macules, papules, vesicles, or bullae.^[2] Historically, erythema multiforme was classified within a spectrum that included Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), but contemporary understanding distinguishes it as a separate entity based on clinical, etiological, and histopathological features.^[5] The modern classification, proposed in seminal works such as Bastuji-Garin et al. (1993), delineates erythema multiforme from SJS/TEN by emphasizing lesion morphology (raised target lesions in EM versus flat atypical targets or macules in SJS/TEN), distribution (acral in EM versus more truncal in SJS/TEN), and extent of mucosal and skin involvement without significant epidermal detachment in EM.^[5]^[4] This separation underscores EM's generally favorable prognosis compared to the more severe, drug-induced SJS/TEN spectrum.^[1] Erythema multiforme is subcategorized into minor and major forms based on severity and extent of involvement. Erythema multiforme minor is confined to the skin, with little to no mucosal involvement, presenting as symmetric, targetoid lesions that resolve within 2 to 4 weeks.^[4] In contrast, erythema multiforme major includes both cutaneous lesions and significant mucosal involvement at two or more sites (e.g., oral, ocular, or genital), but with epidermal detachment limited to less than 10% of the body surface area, excluding it from the SJS category.^[1]^[4] This binary framework aids in clinical management and prognosis assessment, with major forms requiring more intensive supportive care due to potential complications from mucosal erosions.^[1]

Epidemiology

Erythema multiforme (EM) is a rare condition with an estimated annual incidence of 1.2 to 6 cases per million individuals, equivalent to approximately 0.12 to 0.6 per 100,000 population.^[4] Prevalence in the general population is believed to be less than 1%, though exact figures are challenging to ascertain due to underreporting and variable diagnostic criteria.^[1] The condition affects individuals across all age groups but is most prevalent in young adults, with a peak incidence between 20 and 40 years of age; approximately 20% of cases occur in children, while it is uncommon in infants and the elderly.^[1]^[3] Demographically, EM exhibits a male predominance, with a male-to-female ratio of approximately 2:1 to 3:1, though some studies report no overall gender bias except in recurrent pediatric cases where males are more affected.^[4]^[3] There is no clear ethnic or racial predilection, and the disease occurs worldwide without strong geographic clustering, though higher reporting rates may reflect better diagnostic access in developed countries.^[4] Seasonal variations have been observed, with increased cases in spring and summer.^[6] Key risk factors at the population level include a history of HSV infection, which is associated with up to 90% of recurrent EM episodes and elevates the likelihood of future occurrences.^[3] Additionally, post-vaccination cases have been documented, including rare associations with COVID-19 vaccines reported through 2024, with a prevalence of about 0.08% among vaccinated individuals in some cohorts, though overall vaccine-related EM remains infrequent.^[7]

Clinical Presentation

Signs and Symptoms

Erythema multiforme often begins with prodromal symptoms that occur 1 to 14 days prior to the rash onset, including fever, malaise, fatigue, sore throat, cough, or generalized aches, particularly in the major form of the condition.^[1]^[8] These symptoms are typically mild or absent in the minor form and may resemble an upper respiratory infection, affecting 25% to 60% of patients with mucosal involvement.^[3] The hallmark skin manifestation is the development of characteristic target lesions, which start as erythematous macules or papules and evolve over 24 to 72 hours into rounded lesions less than 3 cm in diameter, featuring three concentric zones: a central area of dusky erythema, blistering, or necrosis; a raised, pale edematous ring; and an outer erythematous halo.^[1]^[8] These lesions are symmetrically distributed on acral sites such as the hands, feet, elbows, and knees, with extensor surfaces of the limbs commonly involved, and they may progress to vesicular or bullous forms in more severe cases.^[3] Early lesions can cause a burning or itching sensation, though pruritus is generally absent.^[8] Mucosal involvement occurs in 25% to 60% of cases and is more prominent in the major form, where painful erosions or ulcers develop on the oral, ocular, or genital mucosa, often starting as erythematous or edematous patches that blister and erode into shallow ulcers covered by pseudomembranes or hemorrhagic crusts.^[1]^[3] In the minor form, mucosal lesions are rare and typically limited to a single site, such as the mouth, causing less severe discomfort.^[8] As lesions progress, pain intensifies, especially with mucosal or bullous involvement, potentially leading to difficulties with eating, drinking, or urination.^[3] The rash typically lasts 2 to 4 weeks, with new lesions appearing over the first 3 to 5 days, while individual lesions remain fixed for at least 7 days before resolving without scarring in 7 to 21 days.^[1]^[3] Systemic symptoms beyond the prodrome are uncommon but may include mild fever or regional lymphadenopathy in the major form.^[8] Outbreaks are sometimes preceded by herpes simplex virus infections, though this association is explored further in etiological contexts.^[8]

Variants

Erythema multiforme (EM) is classified into minor and major forms based on the extent of mucosal involvement and severity of skin lesions. EM minor is the most common variant, characterized by predominantly cutaneous involvement with typical or atypical target lesions limited to the extremities and trunk, and featuring few or no mucosal lesions.^[1] It is often associated with herpes simplex virus (HSV) infection as a trigger, presenting as an acute, self-limited hypersensitivity reaction.^[3] In contrast, EM major involves more extensive cutaneous lesions alongside significant mucosal involvement, such as painful oral erosions or ulcers affecting at least one mucosal site, leading to greater symptomatology including discomfort from eating and drinking, though it remains self-limited in most cases.^[9] The distinction between these forms relies on clinical criteria established in seminal classifications, emphasizing mucosal status over body surface area affected. Rare variants of EM deviate further from the classic presentation by incorporating overlapping features with other conditions or unusual triggers. Rowell's syndrome represents a distinctive association of EM-like lesions—annular, targetoid plaques—with features of lupus erythematosus, including positive antinuclear antibody (ANA) in a speckled pattern, anti-Ro/SSA and anti-La/SSB antibodies, and occasionally anti-double-stranded DNA antibodies, typically occurring in middle-aged women with underlying systemic or cutaneous lupus.^[10] EM-like drug eruptions mimic the targetoid morphology but arise primarily from adverse reactions to medications such as anticonvulsants or antibiotics, often lacking the infectious precipitants of typical EM and requiring differentiation through history and histopathology.^[11] Post-infectious forms without HSV involvement include rare cases triggered by zoonotic viruses like orf virus, where target lesions develop 10–14 days after primary inoculation from sheep or goats, or by systemic mycoses such as histoplasmosis, which can manifest as EM during acute primary infection in endemic areas.^[12]^[13] Atypical presentations of EM include persistent and recurrent forms, which challenge the typically self-limited course. Persistent EM is defined by continuous occurrence of typical or atypical target lesions lasting more than three months without complete resolution between flares, often resistant to standard therapies and linked to underlying chronic triggers.^[14] Recurrent EM occurs in up to one third of cases of EM minor, manifesting as multiple episodes over time—sometimes six or more per year—predominantly triggered by HSV reactivation even without overt herpetic symptoms, and requiring prophylactic antiviral management for control.^[3]^[15]^[4]

Etiology and Pathophysiology

Causes

Erythema multiforme is primarily triggered by infectious agents, which account for the majority of cases. Herpes simplex virus (HSV), particularly types 1 and 2, is the most common precipitant, responsible for 70% to 90% of episodes, often occurring 3 to 14 days following viral reactivation.^[14]^[16] Mycoplasma pneumoniae is another significant infectious cause, implicated in 10% to 20% of cases, especially among children, and typically associated with preceding respiratory symptoms.^[17]^[9] Other viruses, such as Epstein-Barr virus (EBV), cytomegalovirus (CMV), and coxsackievirus, have been reported as triggers in isolated cases, while bacterial infections including Streptococcus species and Yersinia enterocolitica are less frequent but documented etiologies.^[18]^[19]^[20] Drug-induced erythema multiforme accounts for approximately 10% of cases, with symptoms usually manifesting 7 to 21 days after initial exposure to the offending agent. Common culprits include sulfonamides, penicillins, anticonvulsants such as carbamazepine, nonsteroidal anti-inflammatory drugs (NSAIDs), and allopurinol.^[21]^[3] Additional triggers encompass vaccinations, autoimmune conditions, and malignancies, though these are infrequent. Reports from 2021 to 2025 document rare instances following COVID-19 mRNA vaccines.^[22]^[23] Autoimmune diseases like sarcoidosis and malignancies such as lymphoma or solid tumors have been associated in exceptional cases.^[3]^[18] Approximately 20% to 30% of cases remain idiopathic, with no identifiable precipitant.^[4]

Pathophysiology

Erythema multiforme arises from a type IV hypersensitivity reaction, characterized by a cell-mediated immune response primarily involving CD8+ T lymphocytes that target keratinocytes expressing foreign antigens, often derived from herpes simplex virus (HSV).^[1] This cytotoxic T-cell activation leads to keratinocyte apoptosis and interface dermatitis, with early infiltration of CD8+ and natural killer T cells promoting inflammation through cytokine release.^[24] Key cytotoxic processes include the release of granulysin from activated T cells, which induces widespread keratinocyte death, alongside involvement of the Fas-FasL pathway and perforin/granzyme B system that facilitate direct cell lysis.^[25] A cytokine storm, featuring elevated tumor necrosis factor-alpha (TNF-α) in drug-induced cases and interferon-gamma (IFN-γ) in HSV-associated cases, amplifies epidermal damage and contributes to the characteristic vacuolar degeneration at the dermoepidermal junction.^[26] In HSV-specific cases, viral DNA fragments persist in epidermal keratinocytes or are transported via CD34+ dendritic cells, triggering an immune attack approximately 7 to 14 days post-infection through recruitment of HSV-specific CD4+ TH1 cells and subsequent IFN-γ production.^[1] Genetic predispositions, including associations with HLA class I and II alleles such as HLA-DQB1*03:01, HLA-B35, and HLA-DR53, increase susceptibility to recurrent episodes by enhancing antigen presentation and T-cell reactivity.^[24] The underlying mechanisms are similar between mucosal and cutaneous sites, but mucosal involvement is more frequent and severe in erythema multiforme major due to heightened antigen presentation and thinner epithelial barriers that facilitate greater immune cell access and tissue vulnerability.^[1]

Diagnosis

Clinical Evaluation

Clinical evaluation of erythema multiforme begins with a detailed history to identify potential triggers and prodromal symptoms. Healthcare providers inquire about recent infections, such as herpes simplex virus outbreaks or Mycoplasma pneumoniae, as these are common precipitants.^[1]^[14] Exposure to new medications, vaccinations, or other allergens within the preceding weeks is also assessed, alongside any preceding symptoms like fever, fatigue, malaise, or arthralgias that may occur 1 to 14 days before lesion onset.^[27]^[1] Physical examination focuses on inspecting the skin and mucous membranes for characteristic features. Lesions are typically examined for acral distribution on the extremities, symmetry, and the presence of target-like lesions—rounded macules or plaques less than 3 cm in diameter with concentric zones of color change—while assessing evolution from erythematous macules to vesicles or bullae.^[1]^[27] Mucosal surfaces, particularly oral, are checked for erosions, bullae, or crusts, with involvement often causing pain or dysphagia; genital or ocular sites are similarly evaluated if suspected.^[14] Systemic signs, including vital signs for fever and general assessment for dehydration or lymphadenopathy, are performed to gauge overall severity.^[1] Severity is classified based on mucosal involvement and skin extent to guide management. Erythema multiforme minor features limited skin lesions with at most one mucosal site affected, often the mouth, and no significant systemic symptoms, whereas major involves severe mucosal involvement at two or more sites with skin lesions typically affecting less than 10% body surface area and possible prodromal illness.^[27]^[1] Criteria exclude Stevens-Johnson syndrome/toxic epidermal necrolysis by absence of widespread epidermal detachment exceeding 10% body surface area or atypical targetoid lesions without true targets.^[14]^[27] Initial red flags during evaluation include rapid lesion progression, extensive mucosal involvement impairing function (e.g., oral erosions preventing eating), or positive Nikolsky sign indicating potential bullous disorders rather than erythema multiforme, where the sign is negative.^[1]^[14] These features prompt urgent differentiation from more severe conditions and may necessitate immediate hospitalization for supportive care.^[27]

Laboratory and Histological Findings

Skin biopsy serves as the gold standard for confirming the diagnosis of erythema multiforme in ambiguous cases.^[1] Histological examination typically reveals vacuolar interface dermatitis characterized by a lymphocytic infiltrate at the dermoepidermal junction, with scattered necrotic keratinocytes and occasional eosinophils.^[28] In more advanced lesions, subepidermal blisters and confluent keratinocyte necrosis may be observed, distinguishing it from other interface dermatitides.^[1] Polymerase chain reaction (PCR) testing on lesion scrapings or biopsy samples detects herpes simplex virus (HSV) DNA in keratinocytes, supporting an HSV-associated etiology; positivity rates range from 50% to 80% in relevant cases.^[29] For suspected Mycoplasma pneumoniae infection, particularly in pediatric patients, IgM serology is recommended, often alongside PCR if available, to confirm recent exposure.^[30] Routine blood tests may show mild leukocytosis, elevated erythrocyte sedimentation rate (ESR), or C-reactive protein (CRP) levels, reflecting the inflammatory response.^[1] A complete blood count (CBC), liver function tests, and renal function tests are useful to rule out systemic involvement or alternative infections, while an autoantibody screen is warranted if an autoimmune trigger is suspected.^[28] Imaging studies, such as chest X-ray, are rarely indicated but may reveal interstitial infiltrates in Mycoplasma-associated cases with respiratory symptoms.^[1]

Management

Acute Treatment

The primary goal of acute treatment for erythema multiforme (EM) is to identify and eliminate precipitating factors while providing symptomatic relief and supportive care to promote resolution of the current episode.^[1] Discontinuation of any suspected offending drugs, such as antibiotics or nonsteroidal anti-inflammatory drugs, is essential and should occur immediately upon suspicion to halt progression.^[3] For cases associated with herpes simplex virus (HSV), early initiation of oral antiviral therapy, such as acyclovir at 400 mg five times daily for 5 to 7 days, can reduce the duration and severity of lesions.^[18] Similarly, if Mycoplasma pneumoniae infection is implicated, appropriate antibiotics like azithromycin may be administered, though evidence for this is limited to treating the underlying infection rather than EM directly.^[31] Symptomatic relief focuses on alleviating discomfort from skin and mucosal lesions. Topical corticosteroids, such as high-potency triamcinolone 0.1% ointment or gel, are applied to cutaneous target lesions and nonerosive mucosal sites to reduce inflammation and itching, typically for 1 to 2 weeks under medical supervision.^[3] Oral analgesics like acetaminophen (up to 1 g every 6 hours as needed) provide pain control, while antihistamines such as diphenhydramine (25-50 mg every 6 hours) may help with pruritus in uncomplicated cases.^[1] For oral erosions, antiseptic mouthwashes (e.g., chlorhexidine 0.12%) or anesthetic rinses containing viscous lidocaine are recommended to soothe pain and prevent secondary bacterial infection, often used multiple times daily.^[18] Supportive care is tailored to the extent of involvement to prevent complications during the acute phase. Wound care for bullous or erosive skin lesions involves gentle cleansing with saline or Burow's solution soaks, followed by nonadherent dressings to minimize infection risk and promote healing.^[1] In cases of severe oral or mucosal involvement impairing intake, intravenous hydration and nutritional support (e.g., via nasogastric tube or total parenteral nutrition) are provided to maintain electrolyte balance and prevent dehydration.^[3] An ophthalmology consultation is indicated for any ocular lesions, with treatments like lubricating eye drops or topical steroids to protect the cornea.^[31] Hospitalization is warranted for the major form of EM or cases with extensive mucosal involvement, systemic symptoms such as high fever, or inability to tolerate oral fluids, where intravenous fluids, close monitoring, and multidisciplinary care can be administered.^[1] In such settings, systemic corticosteroids like prednisone (1 mg/kg/day, tapered over 7-10 days) may be considered for severe inflammation, though their use remains controversial due to limited evidence of benefit in EM and potential risks.^[3]

Prevention of Recurrence

For patients with recurrent erythema multiforme (EM), particularly those associated with herpes simplex virus (HSV), long-term prophylactic antiviral therapy is recommended to suppress future episodes. Continuous oral acyclovir at a dose of 400 mg twice daily, or alternatives such as valacyclovir 500 mg twice daily or famciclovir 500 mg twice daily, is typically initiated for at least 6 months in cases with more than five outbreaks per year or severe manifestations.^[1] A double-blind, placebo-controlled trial demonstrated that continuous acyclovir therapy completely suppresses attacks of recurrent HSV-associated EM in responsive patients, with some achieving disease remission upon discontinuation; in that trial, approximately 64% of treated patients experienced no recurrences during therapy.^[32] In cases of idiopathic or autoimmune-linked recurrent EM unresponsive to antivirals, immunomodulatory agents may be considered. Hydroxychloroquine at 200-400 mg daily has shown benefit in suppressing recurrences, particularly in non-HSV triggered cases.^[15] For refractory disease, options include azathioprine or thalidomide, which have been effective in chronic or persistent EM by modulating immune responses, though use requires careful monitoring for side effects such as hepatotoxicity or neuropathy.^[33]^[34] Lifestyle measures focus on trigger avoidance to minimize recurrence risk. Patients should discontinue or avoid known precipitating agents, such as specific medications or, in rare vaccine-induced cases, certain immunizations if deemed high-risk by a clinician.^[1] For HSV-associated EM, daily antiviral suppression aligns with these preventive strategies.^[16] High-risk patients with recurrent EM warrant regular follow-up to assess treatment efficacy and adjust prophylaxis as needed, especially during the initial 6-12 months of therapy or in cases requiring immunomodulators.^[1]

Prognosis and Complications

Prognosis

Erythema multiforme is a self-limited hypersensitivity reaction with a favorable overall prognosis in most cases. The minor form typically resolves spontaneously within 2 to 3 weeks, whereas the major form often takes 4 to 6 weeks for complete resolution. Cutaneous lesions generally heal without scarring, though temporary postinflammatory hyperpigmentation or hypopigmentation may occur.^[4]^[1] Recurrent episodes occur in up to one-third of cases, particularly those associated with herpes simplex virus (HSV) infection, where recurrences may be frequent. The median interval to recurrence is 6 to 12 months, and recurrent episodes tend to follow a similar clinical course to the initial presentation. Continuous antiviral prophylaxis, such as acyclovir, has been shown to reduce recurrence frequency in HSV-linked cases.^[4]^[3]^[15] Mortality is rare, affecting less than 1% of patients with the minor form and less than 5% with the major form, usually attributable to secondary complications like infection in those with extensive epithelial sloughing. Long-term survival remains excellent, with most patients experiencing full recovery and minimal sequelae.^[4]^[1] Prognostic outcomes are generally better in the minor form compared to the major form and improve with prompt identification and removal of the underlying trigger, such as discontinuing an offending drug or treating an infection. Adverse prognostic factors include extensive mucosal involvement, delayed initiation of supportive care, advanced age, immunosuppression, and concurrent visceral organ involvement.^[4]^[1]

Complications

Erythema multiforme generally resolves without significant sequelae, but severe cases, particularly the major variant, can lead to various short- and long-term complications affecting the skin, mucosa, eyes, and systemic health.^[1] Cutaneous complications include post-inflammatory hyperpigmentation following lesion resolution, which may persist for months.^[3] In cases with bullous lesions, scarring can occur, though it is uncommon in typical erythema multiforme. Secondary bacterial infections may arise from disrupted skin barriers, necessitating antibiotic intervention.^[2]^[1] Mucosal involvement, present in 25% to 60% of cases, can result in scarring and adhesions in oral or genital areas. Esophageal strictures are rare but have been reported in severe presentations, potentially requiring endoscopic management. Vaginal synechiae may develop from erosive lesions, leading to functional impairments.^[3]^[35]^[36] Ocular complications occur in the major variant and include conjunctivitis, keratitis, and symblepharon, affecting mucous membranes and potentially leading to vision loss if not promptly addressed. Ophthalmologic evaluation is essential to mitigate these risks.^[1]^[8] Systemic effects encompass dehydration due to painful oral erosions limiting fluid intake, often requiring hospitalization for supportive care. In hospitalized patients with extensive involvement, secondary sepsis can develop from bacterial superinfection. Chronic sequelae such as recurrent anterior uveitis have been noted in some cases.^[1]^[8] Long-term consequences may involve psychological distress from residual disfigurement or recurrent episodes, impacting quality of life. Rarely, erythema multiforme has been associated with unmasking underlying autoimmune disorders, such as systemic lupus erythematosus.^[2]^[37]

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