Erythema Multiforme at a Glance

Rare cutaneous and/or mucocutaneous eruption characterized by target lesions.

Benign course but frequent recurrences.

Most cases related to herpes simplex virus (HSV) infection. Medications are not frequent
causes.

Frequent recurrences can be prevented by long-term use of anti-HSV medications.

Thalidomide is usually effective in recalcitrant recurrent cases.

Erythema multiforme (EM) is an acute self-limited, usually mild, and often relapsing
mucocutaneous syndrome. The disease is usually related to an acute infection, most often a
recurrent herpes simplex virus (HSV) infection. EM is defined only by its clinical characteristics:
target-shaped plaques with or without central blisters, predominant on the face and extremities.

The absence of specific pathology, unique cause, and biologic markers has contributed to a
confusing nosology. Recent medical literature still contains an overwhelming number of figurate
erythema reported as EM, and the International Classification of Diseases (ICD9) still classifies
StevensJohnson syndrome (SJS) and toxic epidermal necrolysis (TEN) under the heading of
EM.

The definition of EM in this chapter is based on the classification proposed by Bastuji-Garin et

al.1 The principle of this classification is to consider SJS and TEN as severity variants of the
same process, i.e., epidermal necrolysis (EN), and to separate them from EM (see Chapter 40).
The validity of this classification has been challenged by some reports, especially for cases in
children and cases related to Mycoplasma pneumoniae. It has been confirmed by several others
studies however, especially the prospective international Severe Cutaneous Adverse Reactions
study.2 That study demonstrated that, compared with SJS and TEN, EM cases had different
demographic features, clinical presentation, severity, and causes.

The original name proposed by von Hebra was erythema exudativum multiforme. The term
erythema multiforme has now been universally accepted (Box 39-1).

Box 39-1 Erythema Multiforme Subtypes

Box 39-1 Erythema Multiforme Subtypes

Erythema multiforme minor: Skin lesions without involvement of mucous membranes

Erythema multiforme major: Skin lesions with involvement of mucous membranes

Herpes-associated erythema multiforme

 Mucosal erythema multiforme (Fuchs syndrome, ectodermosis pluriorificialis): Mucous
membrane lesions without cutaneous involvement

EM is usually called minor when mucous membranes are spared or minimally affected, for
example, lips, and majus (or major) when at least two mucosal sites are involved.

Epidemiology
EM is considered relatively common, but its true incidence is unknown because largely cases
severe enough to require hospitalization have been reported. Such cases are in the range of 1 to 6
per million per year. Even though the minor form of EM is frequent than the major form, many
other eruptions (including annular urticaria and serum sickness-like eruption) are erroneously
called EM.3

EM occurs in patients of all ages, but mostly in adolescents and young adults. There is a slight
male preponderance (malefemale sex ratio of approximately 3:2). EM is recurrent in at least
30% of patients.

No established underlying disease increases the risk of EM. Infection with human
immunodeficiency virus and collagen vascular disorders do not increase the risk of EM, in
contrast to their increasing the risk of epidermal necrolysis. Cases may occur in clusters, which
suggests a role for infectious agents. There is no indication that the incidence may vary with
ethnicity or geographic location.

Predisposing genes have been reported, with 66% of EM patients having HLA-DQB1*0301
allele, compared with 31% of controls.4 The association is even stronger in patients with herpes-
associated EM. Nevertheless, the association is relatively weak, and familial cases remain rare.

Etiology
Most cases of EM are related to infections. Herpes virus is definitely the most common cause,
principally in recurrent cases. Proof of causality of herpes is firmly established from clinical
experience, epidemiology,2 detection of HSV DNA in the lesions of EM,5,6 and prevention of
EM by suppression of HSV recurrences.7 Clinically, a link with herpes can be established in
about one-half of cases. In addition 10% to 40% of cases without clinical suspicion of herpes
have also been shown to be herpes related, because HSV DNA was detected in the EM lesions by
polymerase chain reaction (PCR) testing.6 EM eruptions begin on average 7 days after a
recurrence of herpes. The delay can be substantially shorter. Not all symptomatic herpes
recurrences are followed by EM, and asymptomatic ones can induce EM. Therefore, this
causality link can be overlooked by both patients and physicians. HSV-1 is usually the cause, but
HSV-2 can also induce EM. The proportion probably reflects the prevalence of infection by HSV
subtypes in the population.
M. pneumoniae is the second major cause of EM and may even be the first one in pediatric
cases.810 In cases related to M. pneumoniae, the clinical presentation is often less typical and
more severe than in cases associated with HSV. The relationship to M. pneumoniae is often
difficult to establish. Clinical and radiologic signs of atypical pneumonia can be mild, and M.
pneumoniae is usually not directly detected. PCR testing of throat swabs is the most sensitive
technique. Serologic results are considered diagnostic in the presence of immunoglobulin (Ig) M
antibodies or a more than twofold increase in IgG antibodies to M. pneumoniae in samples
obtained after 2 or 3 weeks. M. pneumoniae-related EM can recur.11

Many other infections have been reported to be causes of EM in individual cases or small series,
but the evidence for causality of these other agents is only circumstantial. Published reports have
implicated infection with orf virus, varicella zoster virus, parvovirus B19, and hepatitis B and C
viruses, as well as infectious mononucleosis and a variety of other bacterial or viral infections.
Immunization has been also implicated as a cause in children.

Drugs are a rare cause of EM with mucous membrane lesions. Most literature reports of drug-
associated EM actually deal with imitators, for example, annular urticaria12 or maculopapular
eruption with some lesions resembling targets. EM-like dermatitis may result from contact
sensitization. These eruptions should be viewed as imitators of EM, despite some clinical and
histopathologic similarities.

Idiopathic cases are those in which neither HSV infection nor any other cause can be identified.
Such cases are fairly common under routine circumstances. However, HSV has been found in
situ by PCR in up to 40% of idiopathic recurrent cases.9 Some such cases respond to
prophylactic antiviral treatment and are thus likely to have been triggered by asymptomatic HSV
infection; others are resistant.

Pathogenesis
The underlying mechanisms have been extensively investigated for herpes-associated EM.13 It is
unknown whether similar mechanisms apply to EM due to other causes.

Complete infective HSV has never been isolated from lesions of herpes-associated EM. The
presence of HSV DNA in EM lesions has been reported in numerous studies using the PCR
assay. These studies have demonstrated that keratinocytes do not contain complete viral DNA,
but only fragments that always include the viral polymerase (Pol) gene. HSV Pol DNA is located
in basal keratinocytes and in lower spinous cell layers, and viral Pol protein is synthesized. HSV-
specific T cells, including cytotoxic cells, are recruited, and the virus-specific response is
followed by a nonspecific inflammatory amplification by autoreactive T cells. The cytokines
produced in these cells induce the delayed hypersensitivity-like appearance in histopathologic
evaluation of biopsy sections of EM lesions.

HSV is present in the blood for a few days during an overt recurrence of herpes. If keratinocytes
are infected from circulation virus, one would expect disseminated herpes, rather than EM. In
fact, HSV DNA is transported to the epidermis by immune cells that engulf the virus and
fragment the DNA. These cells are monocytes, macrophages, and especially CD34+ Langerhans
cell precursors harboring the skin-homing receptor cutaneous lymphocyte-associated (CLA)
marker. Upregulation of adhesion molecules greatly increases binding of HSV-containing
mononuclear cells to endothelial cells and contribute to the dermal inflammatory response. When
reaching the epidermis the cells transmit the viral Pol gene to keratinocytes. Viral genes may
persist for a few months, but the synthesis and expression of the Pol protein will last for only a
few days. This may explain the transient character of clinical lesions that are likely induced by a
specific immune response to Pol protein and amplified by autoreactive cells. To the best of
current knowledge, the mechanisms and regulation of this immune response are different from
drug reactivity leading to SJS or TEN.14,15

Incomplete fragmentation of viral DNA, increased number of circulating CD34+ cells, and/or
increased immune response to Pol protein may explain why only a small proportion of
individuals with recurrent herpes infections develop EM.

Clinical Findings
The first step is to suspect EM, based on clinical features. A skin biopsy and laboratory
investigations are useful mainly if the diagnosis is not definite clinically. The second step is to
determine whether hospitalization is needed when EM major (EMM) occurs with oral lesions
severe enough to impair feeding, when a diagnosis of SJS is suspected, or when severe
constitutional symptoms are present. The third step is to establish the cause of EM by identifying
a history of recurrent herpes, performing chest radiography, or documenting M. pneumoniae
infection (Fig. 39-1).
Figure 39-1
Approach to the patient with erythema multiforme (EM). ADR = adverse drug reaction; HAEM
= herpes-associated erythema multiforme; IF = immunofluorescence; MP = Mycoplasma
pneumoniae; SJS = StevensJohnson syndrome; URT = upper respiratory tract.

History

Prodromal symptoms are absent in most cases. If present, they are usually mild, suggesting an
upper respiratory infection (e.g., cough, rhinitis, low-grade fever). In EMM, fever higher than
38.5C (101.3F) is present in one-third of cases.2 A history of prior attack(s) is found in at least
one-third of patients and thus helps with the diagnosis. The events of the preceding 3 weeks
should be reviewed for clinical evidence of any precipitating agent, with a special focus on
recurrent herpes.

Cutaneous Lesions
The skin eruption arises abruptly. In most patients, all lesions appear within 3 days, but in some,
several crops follow each other during a single episode of EM. Often there are a limited number
of lesions, but up to hundreds may form. Most occur in a symmetric, acral distribution on the
extensor surfaces of the extremities (hands and feet, elbows, and knees), face, and neck, and less
frequently on the thighs, buttocks, and trunk. Lesions often first appear acrally and then spread in
a centripetal manner. Mechanical factors (Koebner phenomenon) and actinic factors (predilection
of sun-exposed sites) appear to influence the distribution of lesions. Although patients
occasionally report burning and itching, the eruption is usually asymptomatic.

The diversity in clinical pattern implied by the name multiforme is mainly due to the findings in
each single lesion; most lesions are usually rather similar in a given patient at a given time. The
typical lesion is a highly regular, circular, wheal-like erythematous papule or plaque that persists
for 1 week or longer (Fig. 39-2). It measures from a few millimeters to approximately 3 cm and
may expand slightly over 24 to 48 hours. Although the periphery remains erythematous and
edematous, the center becomes violaceous and dark; inflammatory activity may regress or
relapse in the center, which gives rise to concentric rings of color (see Fig. 39-2). Often, the
center turns purpuric and/or necrotic or transforms into a tense vesicle or bulla. The result is the
classic target or iris lesion.
Figure 39-2

Mixture of typical targets and papules in a case of EM minor

According to the proposed classification, typical target lesions consist of at least three concentric
components: (1) a dusky central disk, or blister; (2) more peripherally, an infiltrated pale ring;
and (3) an erythematous halo. Not all lesions of EM are typical; some display two rings only
(raised atypicalMultiple
targets).concentric
However, allvesicular rings
are papular, (herpeswith
in contrast irismacules,
of which are the
bateman). This pattern may be more frequent
typical lesions in epidermal necrolysis (SJSTEN). In some patients with in EM, most lesions are
Mycoplasma
livid vesicles overlying pneumoniae-related
a just slightly casesencircled
darker central portion, of erythema
by an erythematous
multiforme
margin (Figs. 39-3, 39-4, and major.
39-5, Fig. 39-8). Larger lesions may have a central bulla and a
marginal ring of vesicles (herpes iris of Bateman) (Figs. 39-6 and 39-7).

Erythema multiforme major. Mouth lession of EMM

usually manifest as erosions.

Erythema multiforme major. Eye lessions. Conjunctivitis

with erosions

Histopathologic features of erythema multiforme (early

lesion). A. An intense lymphohistocytic infiltrate fills the
mid dermis and obliterates many blood vessels. The
dermal papillare are edematous and contain material
with the staining properties of fibrin. There is sub
epidermal cleft formation and circumscibed necrosis of
the epidermis. B. High power magnification of scattered
keratinocyte necrosis.