jesus, made changes sa last slide (table) and the circles (site of predilection) do we need to...
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Jesus, made changes sa last slide (table) and the circles (site of predilection)
Do we need to distinguish kung EM Minor or Major ung patient?
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ERYTHEMA MULTIFORME
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Erythema MultiformeEM minor & EM with mucosal involvement• Self-limited, recurrent disease• No or only a mild prodrome (1 to 4 weeks)• Sharply marginated erythematous macules
become raised, edematous papules (24 to 48 hours)
• Koebner’s phenomenon or photoaccentuation• Mucosal involvement in 25%
-- usually limited to the oral mucosa• More severe classic case? Two or more
mucous membranes involved in 45%
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EM Minor
• Periphery: ring of erythema
• Central: flatters, more pruritic and dusky
• “target” or “iris” lesion with three zones
Characteristic & Evolution of the Lesion
1. Central dusky purpura2. Elevated, edematous, pale ring3. Surrounding macular erythema
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EM Minor
Sites of Predilection(Symmetrical and acral)• (Best observed on)
Palms and soles• Dorsal feet• Extensor limbs• Elbows• Knees
Age of Predilection• young adults
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Erythema Multiforme
Steven-Johnson syndrome / EM major• Clinically different from minor• Frequently, febrile prodrome
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EM Major
• Flat, erythematous or purpuric macules
incomplete “atypical targets” (may blister centrally
• Larger and more commonly confluent lesions compared to EM minor
Characteristic & Evolution of the Lesion
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EM MajorSites of Predilection• Begins diffusely on the
trunk and mucous membranes
• Spreads centripetally
Age of Predilection• Eruption occurs at all ages
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Etiologic Factors
• EM minor = herpes simplex infection– Typically orolabial– 1 to 3 weeks (10 day average) after herpes lesion– May or not follow herpes outbreaks
• EM major (SJS) = medications– Most centrally accentuated eruptions with atypical targets – Sulfonamides, antibiotics, NSAIDs, allopurinol,
anticonvulsants– Due to abnormal metabolism of medications
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Etiologic Factors
• Also, EM major = Mycoplasma pneumoniae– Prominent mucosal involvement and bullous skin
lesions – NOT classic iris lesions– Resemble SJS cases
• And, EM major = radiation therapy– With phenytoin and tapering corticosteroids –
induces EM starting at radiation port
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Pathogenesis
• Activated T lymphocytes – Epidermis: cytotoxic or suppressor cells – Dermis: helper T cells
• EM minor – specific HLA types (HLA-DQ3)• SJS – abnormalities in drug metabolism
Hence, there is a genetic component for both diseases
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Disease
• Physical examination– Characteristic Target Lesions– Distribution- symmetrical and acral– Evolution:
Diagnosis
Ring of Erythema
Lesions flatten at the center
Center becomes darker and purpuric
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Erythema Multiforme Salient FeaturesEM Minor: Young adultsEM Major: Eruption occurs at all ages
25 year old female
•Sharply marginated erythematous macules•Become raised edematous papules in 24 to 48 hours•Central area may darken and form blisters
Multiple erythematous papules, macules and patches with dark centers5 days duration Appearance of multiple pruritic macules and papules after 2 days
sites of predilection•Dorsum of hands•Dorsum of feet•Extensor limbs•Elbows•Knees•Palms•Soles •Trunk
Flexor surface of both forearms which gradually spread to the face, trunk and thighs, palms and soles