Elsevier

Dermatologic Clinics

Volume 21, Issue 1, January 2003, Pages 195-205
Dermatologic Clinics

Oral manifestations of erythema multiforme

https://doi.org/10.1016/S0733-8635(02)00062-1Get rights and content

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The spectrum of EM

Erythema multiforme was first described by Hebra [1] in 1866 as a relatively benign condition characterized by skin lesions with concentric color changes, which were symmetrically distributed. Lesions of EM are located primarily on the extremities and have a tendency to recur. The disease tends to have an episodic course with duration of 1 to 4 weeks. It usually occurs in young healthy individuals. The entity described by Hebra [1] did not mention mucosal involvement, but most authors have

Classification of EM

The spectrum of disease discussed under the rubric of EM includes (1) EM minor, (2) EM major, (3) SJS, (4) TEN, and (5) oral EM Table 1, Table 2.

EM minor and major

Erythema multiforme minor and major may occur in patients of all ages, but it is most often seen in adolescents and young adults. It is often recurrent. The cause of both EM minor and major is usually related to an infectious agent. Herpes simplex virus (HSV) infections are implicated in 50% of patients with EM. Both HSV-1 and HSV-2 infections may trigger EM. Half of the acute episodes of EM and about 80% of the recurrent episodes have been associated with HSV infections [5], [13], [20]. Other

EM minor

By definition, some authors state that EM minor patients do not have oral lesions [9], [11], [13]. Most authors accept mild erythematous patches or superficial erosions of the oral mucosa or lips as part of the EM minor spectrum.

EM major

Oral involvement is common because 40% to 60% of patients have oral lesions [9], [11], [13]. Lesions are typically seen in the anterior part of the mouth, on nonkeratinized mucosa and less frequently on the gingivae [25]. The lesions appear clinically as erythematous

Erythema multiforme

In early classic EM with target lesions, a prominent dermal inflammatory reaction with edema, vasodilation, and a lymphohistiocytic infiltrate around blood vessels is noted (Fig. 11). There is little epidermal change. There may be some vacuolar degeneration of the lower epidermis or individually necrotic epidermal cells. Dramatic necrosis of the whole dermis is seen in more severe bullous cases [16], [22]. Accumulation of mononuclear cells around the upper dermal blood vessels is the pathologic

Erythema multiforme

In typical cases, the skin lesions of EM should not be confused with other conditions because of the characteristic symmetric acral distribution of the targetoid or bullous lesions. EM is a relapsing condition that is most often etiologically related to HSV infection. Extracutaneous involvement occurs in EM major and is most often limited to the oral mucosa. Laboratory test results are usually normal. Patients with severe EM major may have an elevated erythrocyte sedimentation rate, moderate

Erythema multiforme

In most cases, once the disease is established, EM minor causes minimal discomfort and regresses spontaneously in 2 to 4 weeks. Therapy is similar for EM minor and major with the addition of oral care for oral mucous membrane involvement in EM major. In general, treatment depends on the severity of the condition. If manifestations are mild, symptomatic, conservative care is usually adequate. This may include systemic or topical analgesics, and antibiotic treatment for secondarily infected

Summary

Erythema multiforme is a reactive mucocutaneous disorder in a disease spectrum that comprises a self-limited, mild, exanthematic, cutaneous variant with minimal oral involvement (EM minor) to a progressive, fulminating, severe variant with extensive mucocutaneous epithelial necrosis (SJS and TEN). Significant differences exist among EM minor, EM major, SJS, and TEN with regards to severity and clinical expression; however, all variants share two common features: typical or less typical

Acknowledgements

The authors are grateful to Dr. Francesco Boin for his assistance.

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