Erythema Multiforme in a Woman and in a Man

October 1, 2002

For 2 days, a 43-year-old woman has had a slightly tender rash on her trunk andextremities. Five days earlier, the patient was given levofloxacin for an upperrespiratory tract infection; because she is prone to yeast infections while takingantibiotics, fluconazole also was prescribed.

Figure 1

Case 1:
For 2 days, a 43-year-old woman has had a slightly tender rash on her trunk andextremities. Five days earlier, the patient was given levofloxacin for an upperrespiratory tract infection; because she is prone to yeast infections while takingantibiotics, fluconazole also was prescribed. Her only other medication is an oralcontraceptive, which she has been taking for several years.

What is the likely cause of this rash?
A. A drug reaction to the levofloxacin.
B. A drug reaction to the fluconazole.
C. A drug reaction to the oral contraceptive.
D. A reaction to the underlying respiratory tract infection.
E. Urticaria caused by either the infection or the antibiotic.

What action do you take?
F. Perform a skin biopsy.
G. Discontinue the levofloxacin.
H. Discontinue the fluconazole.
I. Discontinue the oral contraceptive.
J. Prescribe an antibacterial agent that is not a fluoroquinolone.

Figure 2

Case 2:
For 5 days, a 38-year-old man has been bothered by a slightly itchy and slightlytender rash on the trunk, legs, arms, and hands. He denies any previoussimilar episodes. The patient recently completed a 5-day course of an antiviralagent he has used before to treat recurrent herpes labialis. He takes no othermedications.

Can you identify this condition?
A. Disseminated herpes simplex.
B. A fixed drug eruption.
C. A maculopapular drug eruption.
D. Erythema multiforme.
E. Psoriasis.

How would you proceed?
F. Prescribe another course of the antiviral therapy at a doubled dose.
G. Prescribe a corticosteroid cream.
H. Prescribe a systemic corticosteroid.
I. Prescribe calcipotriene cream.
J. Perform a skin biopsy.
K. Watch and wait for self-resolution.

Figure 1

Case 1: This is erythema multiforme,a self-limited, usually mild and relapsingexanthematic, cutaneous, intolerancereaction. This patient had nohistory of recurrent herpes simplexvirus infection, which is often relatedto erythema multiforme (see Case 2).Other infectious agents, particularlyMycoplasma pneumoniae, and drugsalso have been linked to the skindisease.

This patient's eruption most likelywas caused by an M pneumoniaeupper respiratory tract infection, D, orby the levofloxacin, A, which cancause erythema multiforme. The antibiotic was discontinued immediately, G.An erythromycin-based agent, J, and a short, tapered course of prednisonewere prescribed; the patient recovered uneventfully.

The characteristic target-shaped, urticarial plaques of erythema multiformemay involve the trunk; the extremities, including palms and soles; andfrequently the mucous membranes. The condition is relatively common; it mayaccount for up to 1% of dermatologic outpatient visits.1 Because the lesions ofacute annular urticaria-an often drug-induced hypersensitivity syndrome-look similar to those of erythema multiforme, the two disorders can be confused.However, urticaria is usually transient and highly pruritic. Perform askin biopsy if the diagnosis is in doubt.

REFERENCE:1. Freedberg IM, Eisen AZ, Wolff K, et al, eds. Fitzpatrick's Dermatology in General Medicine. 5th ed. New York:McGraw-Hill; 1999.

Figure 2

Case 2:
The occurrence of "target" lesionswith a vesicular center followinga herpes simplex virus infection and involvementof the palms is a classic presentationof erythema multiforme, D(see Case 1). A skin biopsy, J, can helpconfirm the diagnosis. This patient'sdisease did not respond to a systemiccorticosteroid, H; rather, this self-limitederuption ran the typical benigncourse and resolved in 3 weeks, K.

Disseminated herpes simplexdoes not usually affect an immunocompetenthost. Unlike the rash inthis patient, a fixed drug eruption presentsinitially with a single lesion.Adverse drug reactions to antiviral therapy are very rare; even when a skinbiopsy is performed, it is difficult to distinguish such a reaction from erythemamultiforme. However, if desired, a drug rechallenge may be tried to confirman adverse reaction. The vesiculation and target lesions on the palms seenhere are not characteristic of psoriasis, which features scalier, more pruriticlesions.

Figure 1

Case 3:
The parents of a 9-year-old girl are concerned about theirdaughter's rash that developed 1 week earlier. The asymptomaticeruption is primarily on the trunk. The patienthas no history of exposure, takes no medication, and hasnot had any recent illnesses. The family pets include adog and a cat.

What is the cause of this patient's rash?
A. Pityriasis rosea.
B. Psoriasis.
C. Tinea corporis.
D. Nummular eczema.
E. Contact dermatitis.

What is your next step?
F. Perform a potassium hydroxide evaluation.
G. Prescribe an antifungal cream.
H. Prescribe a corticosteroid cream.
I. Prescribe an antifungal/corticosteroid cream.
J. Recommend a change of detergent and fabric softener.

Figure 2

Case 4:
A 52-year-old woman presents for evaluation of a slightly pruritic rash of 2 weeks'duration. The eruption is confined to one buttock. The patient denies any previousepisodes or exposure to irritants or contactants. She is otherwise healthy, visitsa health club regularly, and owns 2 cats.

Which condition do you suspect?
A. Psoriasis.
B. Seborrhea.
C. Tinea corporis.
D. Herpes simplex.
E. Herpes zoster.

Your initial strategy is to . . .
F. Perform a potassium hydroxide evaluation.
G. Perform a viral culture.
H. Prescribe a corticosteroid cream.
I. Prescribe an antifungal cream.
J. Prescribe an oral antiviral antibiotic to cover herpes simplex virus andvaricella-zoster virus.

Figure 1

Case 3:
Circular patches of scalingand erythema are clues to pityriasisrosea, A, a self-limited disease thatmay last for weeks to months. Thispatient exhibits signs of both the commonlyoccurring form of the disorderand a papular variant. A corticosteroidcream, H, and the anti-inflammatoryeffect of moderate exposure to sunlightcleared the outbreak.

Psoriasis in this age group usuallyfollows a streptococcal infection; thispatient had no such history. Her rashwas far too extensive to be tinea corporis.She had no history of atopy,which made nummular eczema unlikely.Contact dermatitis is pruritic andnot as discrete as this patient's lesions.

Figure 2

Case 4:
A potassium hydroxide evaluation, F, confirmed the diagnosis of tineacorporis, C. The outbreak's location suggests that the patient had picked upthe dermatophyte from a surface on which a cat had shed spores or from exposureat her health club. Treatment with an antifungal cream, I, was successful.To prevent recurrence, we recommended that the cats be treated.

Herpes simplex and herpes zoster outbreaks are more vesicular; self-limited;and crusting, especially 2 weeks after eruption. The lesions of psoriasisand seborrhea are more pruritic and, unlike this patient's rash, they are classicallyfound above the superior aspect of the gluteal crease.

  

Case 5:
During the past few weeks, itchy papules have developedprimarily on this 47-year-old man's extremities. The lesionslast for a few weeks, then crust and disappear while newcrops erupt. The patient denies fever, body aches, and jointpain. His only medication is atorvastatin, which he hasbeen taking for several years.

What does this look like to you?
A. An adverse reaction to the cholesterol-lowering agent.
B. Scabies.
C. Bacterial folliculitis.
D. Pityriasis lichenoides.
E. Insect bites.

Your initial approach is to . . .
F. Perform a skin biopsy.
G. Perform a bacterial culture.
H. Perform a scabies preparation by scraping the skinto uncover the mite's burrow.
I. Discontinue the atorvastatin.
J. Recommend insect repellent.

Figure 1

Figure 2

Case 6:
A 42-year-old woman presents with a 2- to 3-week historyof a pruritic rash on her trunk and extremities. She deniesany previous illnesses or rashes and takes no medications.The patient is an active woman who enjoys riding horsesand gardening.

What are your thoughts? Is the diagnosis . . .
A. Psoriasis.
B. Pityriasis rosea.
C. Lichen planus.
D. Erythema multiforme.
E. Tinea corporis.

Your initial approach is to . . .
F. Perform a skin biopsy.
G. Perform a potassium hydroxide evaluation.
H. Prescribe a corticosteroid cream.
I. Prescribe a systemic corticosteroid.
J. Recommend moderate sunlight.

Figure 1

Case 5:
A skin biopsy, F, confirmed the clinical impressionof pityriasis lichenoides, D. The more common chronicform of the disease is characterized by successive cropsof asymptomatic, erythematous, scaly papules that canpersist for months. Pityriasis lichenoides et varioliformisacuta (PLEVA), the acute form of the disorder that is seenin this patient, features acute exacerbations that can recurand may be associated with vesiculopustular lesions, ulceration,hemorrhage, and crusting.

The acute and chronic variants may develop independently,concurrently, or sequentially. This condition isthought to be an immunologic reaction to an infectiousagent; the reaction comprises both immune complex diseaseand a cell-mediated hypersensitivity response.

Topical corticosteroids and antihistamines decreasethe inflammation but do not substantially affect the diseasecourse. The systemic and skin symptoms of PLEVAcan be ameliorated by prednisone, 40 to 60 mg/d. Antibiotics,such as tetracycline (2 g/d for 4 weeks in adults) orerythromycin (2 g/d in adults and 50 mg/kg/d in children),may be tried. This patient recovered after a 3-weekcourse of erythromycin.

Insect bites and scabies are more pruritic than thispatient's lesions; drug reactions usually are not confinedto the extremities and do not erupt in crops. A bacterialfolliculitis tends to be more painful than pruritic and mayexhibit occasional pustules.

Figure 2

Case 6:
A skin biopsy, F, confirmedthe clinical impression of lichenplanus, C, with its characteristic flattopped,polygonal, purple, pruriticpapules. The eruption, which can lastfor 1 to 2 years, may wax and wanespontaneously and can involve varioussites.

At least two thirds of patients arebetween the ages of 30 and 60 years.Reportedly, cutaneous and mucosallichen planus affects women moreoften than men.

Management of this benign diseasecan be a challenge. A systemiccorticosteroid (eg, prednisone, 30 to 60mg/d for 4 to 6 weeks, then tapered over another 4 to 6 weeks) can amelioratesymptoms and may stave off recurrences. This patient responded well to systemiccorticosteroid therapy, I, and remains in remission several months later.More scale is apparent in psoriasis, tinea corporis, and pityriasis rosea.Erythema multiforme does not erupt as discrete, purple papules.