Erythema Multiforme on Hands of a 55-Year-Old Woman

Painful, 1- to 1.5-cm macules and papules had developed on the palms and dorsal hands and wrists of a 60-year-old man 2 weeks earlier, after a deer-hunting trip. He had not seen any ticks on his skin or clothing. The lesions persisted despite self-treatment with over-the-counter topical corticosteroids. The patient had general malaise but denied fever, chills, and arthralgia. He was not taking any medications.

On further examination, Shannon E. Whitten, RN, MS, NP-C, CCRN, of Tennille, Ga, noted a crusted, weeping vesicle on the patient's upper lip, consistent with herpes labialis. Erythema multiforme (EM) preceded by a herpes simplex virus (HSV) infection was diagnosed.

The HSV antigen in the epidermis is believed to activate the alternate complement pathway that leads to a complex immune response. HSV infection is the most frequent cause of EM (79% to 90% of cases).^1,2 Other types of infection, as well as medications (eg, penicillin), malignancy, and vaccines, have been known to cause EM. The condition may be idiopathic.

The diagnosis is based on the classic morphology of the lesions. The differential diagnosis includes psoriasis; secondary syphilis; pemphigus; systemic lupus erythematosus; fixed drug eruption, especially with recurrent EM; erythema nodosum; toxic epidermal necrolysis; acute herpetic gingivostomatitis; urticaria; and vasculitis. Immunofluorescence can rule out pemphigoid and linear IgA disease in atypical presentations.¹ Biopsy may assist diagnosis in patients who have suspicious mucous membrane lesions but no skin involvement.

Milder forms of EM often resolve within 1 to 2 weeks, leaving residual hyperpigmentation. The lesions resemble a target or iris, with concentric rings of grayish or purpuric discoloration. They are typically found on extensor surfaces of the elbows and knees; the dorsa of the hands, forearms, and feet; and the face, penis, and vulva.They can be asymptomatic or pruritic and painful. About 22% to 37% of patients with EM after an HSV infection have recurrent episodes.¹

Severe forms of EM may last several months and are associated with significant morbidity and mortality. Symptoms include fever, arthralgia, and prostration. Skin lesions may become vesicular, bullous, and confluent. Mucous membrane lesions can cause stomatitis, vulvitis, and balanitis. Conjunctivitis may lead to keratitis and even ulcerative eye lesions.

Treatment consists of supportive care in addition to management or removal of the underlying cause. Therapeutic options include antihistamines, sulfadiazine cream, analgesics, and mouthwash (for oral lesions). Recurrent EM may be treated with an antiviral agent; however, antivirals offer little benefit once an eruption occurs.^1,3 Thalidomide may reduce the duration of an outbreak and maintain remission in recurrent EM.^1,4 For confirmed EM that fails to respond to antiviral therapy, alternative measures include dapsone, antimalarial agents, and azathioprine.⁵

This patient was treated with oral valacyclovir, 2 g bid for a total of 2 doses, and topical acyclovir, applied to the lip lesion 4 or 5 times daily until the lesions resolved. At follow-up, the infection had not recurred.

References:

REFERENCES:

1.

Arndt K, Bowers K.

Manual of Dermatologic Therapeutics

. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2002:80-83.

2.

Tierney L Jr, Mcphee S, Papadakis M.

Current Medical Diagnosis and Treatment.

38th ed. Stamford, Conn: Appleton & Lange; 1999:153-154.

3.

Fitzpatrick T, Johnson A, Polana M, Suurmond D.

Color Atlas & Synopsis of Clinical Dermatology.

4th ed. New York: McGraw-Hill; 1997:332-334.

4.

Cherouati K, Claudy A, Souteyrand P, et al. Treatment by thalidomide of chronic erythema multiforme: its recurrent and continuous variants. A retrospective study of 26 patients [in French].

Ann Dermatol Venereol.

1996;123:375-377.

5.

Hoffman LD, Hoffman MD. Dapsone in the treatment of persistent erythema multiforme.

J Drugs Dermatol

. 2006;5:375-376.