Erythema Multiforme

A Review of Epidemiology, Pathogenesis, Clinical

Features, and Treatment

Firoozeh Samim, DMD, MSca, Ajit Auluck, BDS, MDS, PhD

b
,
Christopher Zed, DDS, MBAc,
P. Michele Williams, BSN, DMD, FRCD(C)c,*

KEYWORDS
 Erythema multiforme  Oral ulcer  Vesiculobullous  Immune disorder  Ulcerative
 Stevens–Johnson syndrome

KEY POINTS
 Erythema multiforme (EM) is a widespread hypersensitivity reaction that occurs with vary-
ing degrees of severity.
 Herpes simplex virus (HSV) infection is the most common precipitator of EM, and the pos-
sibility of HSV-induced disease should be considered in all patients.
 The history of lesion eruption and related clinical findings provides the most important in-
formation for the diagnosis of EM. Patients should be queried regarding prodromal symp-
toms as well as recent introduction of any new medications.
 The clinical course of EM is usually self-limiting, resolving within weeks without significant
sequelae. However, in a minority of cases, the disease recurs frequently over the course of
years.
 Most patients with EM can be managed with symptomatic therapy alone. However, pa-
tients with severe EM may require hospitalization for hydration, analgesia, antiviral ther-
apy, and systemic steroids.

INTRODUCTION

Erythema multiforme (EM) may be seen in the dental setting, and the acute onset
of the condition results in the need for prompt diagnosis and care. This acute
immune-mediated disorder affects the skin and/or mucous membranes, including

A version of this article appeared as Williams PM, Conklin R. Erythema multiforme: a review
and contrast from Stevens-Johnson syndrome/toxic epidermal necrolysis. Dent Clin N Am
2005;49:67–76.
a
Faculty of Dentistry, University of British Columbia, Vancouver, British Columbia, Canada;
b
Simon Fraser University, Vancouver, British Columbia, Canada; c Faculty of Dentistry, Univer-
sity of British Columbia and Vancouver General Hospital, Vancouver, British Columbia, Canada
* Corresponding author. Gordon and Leslie Diamond Health Care Centre, #7299A, Level
7 - 2775 Laurel Street, Vancouver, British Columbia V5Z 1M9, Canada.
E-mail address: mwill@bccancer.bc.ca

Dent Clin N Am 57 (2013) 583–596

http://dx.doi.org/10.1016/j.cden.2013.07.001 dental.theclinics.com
0011-8532/13/$ – see front matter Ó 2013 Elsevier Inc. All rights reserved.
584 Samim et al

the oral cavity.1 It is a blistering, ulcerative, mucocutaneous condition that is charac-

terized by target or iris lesions distributed symmetrically on the extremities and trunk.2
EM has a wide spectrum of clinical manifestations that may be triggered by hypersen-
sitivity reactions to various antigens and has a tendency to recur.3,4 Clinical classifica-
tion of EM is typically based on the severity of the condition, including EM minor (EMm)
and EM major (EMM).5 Similarities in clinical and histopathologic findings have led to
controversy over the distinction between EM and Steven Johnson syndrome (SJS).
However, there is increasing evidence to suggest that EM is a condition distinct
from SJS and toxic epidermal necrolysis (TEN) due to differences of potential causes,
clinical presentation, patient demographics, and pathology.6,7 The purpose of this
article is to review the epidemiology, pathogenesis and clinical features of erythema
multiforme and to discuss the importance of early diagnosis and prompt treatment
of the condition.

EPIDEMIOLOGY

The reported epidemiologic data related to EM is scarce. This is likely because of the
acute nature of the condition, the absence of a universally accepted classification sys-
tem, and the lack of a reporting registry. The reported prevalence rate of erythema
multiforme is less than 1%.8 A summary of the overall incidence of hospitalization
for EM is documented in Table 1.
EM typically occurs in young adults 20 to 40 years of age9 and is more common in
women compared with men (1.5:1.0).10 There is a reported recurrence rate of 37%11
and a genetic predisposition to certain Asian ethnic groups.12 Prevalence rates of oral
EM lesions vary from 35% to 65% among patients with cutaneous lesions. Mortality
rates of EM are not well documented. The literature does suggest however that 5%
of SJS to 30% of TEN may be fatal.13

ETIOLOGY AND PATHOGENESIS

EM arises as a consequence of immune-complex mechanisms involving antigen-

antibody reactions that target small blood vessels in the skin or mucosa. In approxi-
mately 90% of cases, the precipitating event relates to infection, with the herpes

Table 1
Summary of epidemiologic studies of erythema multiforme reporting the global incidence
rates

Annual Incidence Rate

of EM Group Requiring
Study Study Duration Location Hospitalization per 1 Million
Chan et al,33 1990 1972–1986 Washington 4.2
Kamaliah et al,34 1998 1987–1994 Malaysia 2.1
Schöpf et al,35 1991 1981–85 Germany 1.01
Strom et al,36 1991 1980–1984 3 US states 39.9
Farthing et al,28 1995 — England 5/10
Roujeau & Stern,37 1994 — Sweden 0.4–6
Forman et al,38 2002 1985–1995 Ontario, Canada 6
Mittmann et al,39 2004 1995–2000 Canada 1.5
Sanchis et al,40 2010 — Spain 0.8–6
 Erythema Multiforme 585

simplex virus playing a predominant role in 70% to 80% of cases.14 Other precipitating
or triggering factors may include medications, especially sulfonamides, nonsteroidal
anti-inflammatories, penicillins, and anticonvulsants. Although less common, genetic
factors, neoplastic conditions (renal and gastric carcinoma), autoimmune disease
(inflammatory bowel disease), radiation, and food additives/chemicals have also
been reported.15,16 Certain human leukocyte antigen (HLA) phenotypes, such as
HLA 36 and HLA 35 may predispose patients to develop recurrent EM in response
to a range of stimuli.17–19 The summary of etiologic associations with EM is presented
in Table 2.

Table 2
Etiologic factors for developing erythema multiforme

Infections Viral in descending Herpes viruses; HSV-1 and HSV-2, Epstein-

Approximately order of incidence Barr virus, cytomegalovirus, varicella-
in 90% of cases zoster virus
Adenoviruses
Enteroviruses; coxsackie virus B5, echoviruses
Bacterial in descending Mycoplasma pneumoniae
order of incidence Corynebacterium diphtheriae
Hemolytic streptococci
Legionella pneumophila
Salmonella
Mycobacterium leprae
Pneumococcus
Drugs (less than Highly suspected in Sulfonamides (trimethoprim,
10% of cases) descending order sulfamethoxazole)
of incidence Nonsteroidal anti-inflammatory drugs
Penicillins
Anticonvulsants (barbiturates,
carbamazepine)
Hydantoids
Valproic acid
Allopurinol
Antifungal (Terbinafine)
Oxicama (piroxicam, tenoxicam)
Others Imidazole
Chlormezanone
Systemic corticosteroids
Cephalosporins
Quinolones
Tetracycline
Immune condition Immune disease Graft versus host disease
Inflammatory bowel disease
Polyarteritis nodosa
Sarcoidosis
Systemic lupus erythematous
Immunization Bacille Calmette-Guérin, hepatitis B and
smallpox immunization
Others Food additives Benzoates
Nitrobenzene
Chemicals Perfume
Terpenes
a
Members of a class of nonsteroidal anti-inflammatory drugs that bind closely to plasma proteins.
586 Samim et al

The most common trigger for the development of EM is the herpes simplex virus
(HSV-1 and HSV-2).4,14 This association is supported by the detection of HSV DNA
in 60% of patients clinically diagnosed with recurrent herpes-associated EM
(HAEM) and in 50% of patients with recurrent idiopathic EM using polymerase chain
reaction (PCR) of skin biopsy specimens.18 In most cases of cutaneous EM, HSV-1
had a predominant role with reported prevalence of HSV-1 in 66.7% of cases,
HSV-2 in 27.8% of cases, and with both HSV types in 5.6% of cases.20
The pathogenesis pathway of EM has been based on investigative studies of HAEM.
It has been suggested that an autoreactive T-cell trigger by viral antigen-positive cells
containing the HSV-DNA polymerase gene play an important role.21 EM is initiated by
the expression of HSV-DNA fragments that are transported and generated by periph-
eral blood mononuclear cells (PBMCs), principally macrophages and CD341 Langer-
hans cell (LC) precursors, presumably by the vascular route. Inflammatory responses
are initiated by viral gene expression in the skin and the recruitment of HSV-specific
CD41 T-helper 1 (Th1) cells. Interferon gamma (IFN-g) generated by this response
upregulates cytokines and chemokines that amplify cutaneous inflammatory events
both with increased sequestration of circulating leukocytes, monocytes, and natural
killer (NK) cells and with the recruitment of autoreactive T-cells to the epidermis
(Figs. 1 and 2).21 The mechanism of autoreactive T-cell generation is still unclear.
The outcome is epidermal damage resulting from lysis of surrounding keratinocytes,
release of various cytotoxic factors, keratinocyte growth arrest, and apoptosis. The
HSV-DNA polymerase gene is located in the basal keratinocyte and lower spinous
cell layers.22,23 In contrast to viral-associated EM, drug-induced erythema multiforme
is associated with tumor necrosis factor-a (TNF-a), perforin, and granzyme B, which
cause the epidermal destruction seen in the disease with involvement of CD81

Fig. 1. Seven to 21 days after primary or recurrent viral infection, circulating PBMCs, macro-
phages, and CD341 Langerhans cells engulf HSV-DNA, and migrate to epidermis to transfer
this antigen to keratinocytes. It has been suggested that HSV-DNA fragments in circulating
or decaying PBMCs are released at the time of PBMC deposition on the skin.
 Erythema Multiforme 587

Fig. 2. Expression of HSV DNA in keratinocytes leads to activation of HSV-specific CD41 Th1
cells, which produces interferon g. Epidermal cell damage results from attacks by cytotoxic
T-cells, NK cells, and monocytes.

T-cell attacks.21 A summary of clinical and histopathological features of HAEM and

drug-induced EM is presented in Table 3.

CLINICAL PRESENTATION

The term EM was coined to reflect the multiple and varied clinical appearances that
are associated with this condition. The clinical behavior of EM can be divided into

Table 3
Clinical and histopathological difference between HAEM and drug-induced EM

HAEM Drug Induced EM

Etiology HSV-1, HSV-2 Drugs
Clinical features No or mild prodromal signs/ Flu-like prodrome, acute, self-
symptoms; acute; self-limiting; limiting, not recurrent
recurrent
Predilection site Skin: acral extremities, target Skin: acral extremities, blisters
lesions Mucosal lesions (in most cases oral
Mucosal lesions are absent/and mucosa): prominent
oral lesions are minimal
Histopathology Focal keratinocyte necrosis; Extensive keratinocyte necrosis;
edema; predominant less edema; predominant
mononuclear infiltration: CD41 mononuclear infiltration: CD41
Immunochemistry Positive for HSV DNA-PCR and Negative for HSV DNA PCR;
interferon g positive for tumor necrosis
factor a
Mortality Not reported 5%–15%

Abbreviations: EM, erythema multiforme; HAEM, herpes-associated erythema multiforme; HSV,

herpes simplex virus; PCR, polymerase chain reaction.
588 Samim et al

3 major subgroups that include classical erythema multiforme, recurrent erythema

multiforme, and persistent erythema multiforme.24 The frequent occurrence of EM
over a period of years is known as recurrent erythema multiforme.25 Persistent EM
is a rare condition characterized by the continuous occurrence of typical and atypical
lesions without interruption.26,27 With classic and recurrent disease, there may be pro-
dromal symptoms that precede the eruption of lesions. Young adults are most
commonly affected and there can be seasonal clustering in the spring or fall.28
When HSV is the triggering factor, EM (minor or major) lesions typically begin 10 to
14 days following a recurrent HSV infection (lip most commonly involved).29

CUTANEOUS FEATURES

Rarely, there may be prodromal symptoms (ie, fever, malaise, headache, cough,
rhinitis, sore throat, myalgia, arthralgia, nausea) associated with erythema multiforme,
which typically occur 7 to 14 days before cutaneous lesion development. The classic
skin lesion of EM is a target or iris lesion (Fig. 3) characterized by concentric erythem-
atous rings separated by rings of near normal color with lesion size ranging from
2 to 20 mm.4 Typically, there is a symmetric distribution of lesions over the extremities
(dorsal surfaces of hands, feet, elbows, and knees). The lesions are usually asymp-
tomatic, although burning or itching sensations have been reported. Less common
skin manifestations of EM include macules, papules, vesicles, bullae, and urticarial
plaques. Complete recovery from an EM attack typically occurs within 1 to 4 weeks.
No scarring occurs. Transient hypopigmentation or hyperpigmentation may be seen.4

ORAL MANIFESTATIONS

Oral mucosal lesions occur in more than 70% of EM cases. EM may also present as
oral mucosal ulcerations with few or no skin lesions.30 There may be considerable vari-
ability in the appearance of oral lesions, ranging from diffuse oral erythema to multi-
focal superficial ulcerations. Initially, vesicles or bullae may also be present. Any
area of the mouth may be involved, with the buccal mucosa, palate, and tongue being
most frequently affected. In most cases, lip lesions are observed that show hemor-
rhagic crusting of the lips (Fig. 4). There may be mild to severe oral and perioral
pain that may compromise speech, eating, and fluid intake. Lip and oral lesions
heal without scarring.4
A summary of the similarities and differences between EM, as well as SJS/TEN is
presented in Table 4.

Fig. 3. Target lesions characteristic of EM. (Courtesy of Thomas P. Sollecito, DMD, FDS, RCS,
Philadelphia, Pennsylvania.)
 Erythema Multiforme 589

Fig. 4. Hemorrhagic crusting of the lips with tongue ulceration in EM.

HISTOPATHOLOGICAL FEATURES

The histologic feature of peri-lesional tissue in erythema multiforme reveals some

characteristic features but none that are pathognomonic of the disease. The histologic
features are variable and this is reflective of the wide spectrum of clinical presenta-
tions. Some features consistently observed include intercellular and intracellular
edema of the overlying epithelium, focal microvesicle formation, keratin mucopolysac-
charide dystrophy, pooling of an eosinophilic amorphous coagulum within the epithe-
lium, and infiltration of mononuclear and polymorphonuclear cells into all epithelial
layers (Figs. 5 and 6). There may also be acanthosis and elongation of rete pegs,
generalized diffuse infiltrate of mixed mononuclear cells of the upper portion of the
lamina propria, and vasodilation of blood vessels with marked connective tissue
edema causing large zone separation at the basement membrane level.3 Immunoflu-
orescence testing reveals that deep perivasculitis is positive for immunoglobulin
M and C3.31

Fig. 5. Histopathology (hematoxylin-eosin [H&E] staining, magnification 10) of EM (buccal

mucosa). Intercellular and intracellular edema of the overlying epithelium, focal microvesicle
formation, keratin mucopolysaccharide dystrophy, pooling of an eosinophilic amorphous co-
agulum within the epithelium, and infiltration of mononuclear and polymorphonuclear cells
into all epithelial layers.
590 Samim et al

Fig. 6. Histopathology (H&E staining, magnification 10) of EM (skin of finger). Acanthosis

and elongation of rete pegs, generalized diffuse infiltrate of mixed mononuclear cells of the
upper portion of the lamina propria, and vasodilation of blood vessels with marked connec-
tive tissue edema.

DIAGNOSTIC TECHNIQUES AND EVALUATION OF EM

The diagnosis of EM is mainly based on the history and clinical presentation, as histo-
pathologic features and laboratory investigations are nonspecific. Typically, the his-
tory includes acute onset of oral and/or skin lesions, possibly preceded by an HSV
infection or a history of recent drug intake. This history, combined with characteristic
target lesions of the skin and mucous membranes, supports the diagnosis of EM.
Direct and indirect immunofluorescence may help in distinguishing EM from other
types of vesiculo-bullous lesions. On an individual case basis, a Tzanck smear,
swab for HSV-PCR, or other serologic investigations may be helpful in ruling out an
inflammatory, autoimmune, or malignant disorder.

DIFFERENTIAL DIAGNOSIS

The patient history and clinical presentation should provide the most pertinent infor-
mation in making a diagnosis of EM. However, other conditions considered in the dif-
ferential diagnosis are primary HSV gingivostomatitis, autoimmune vesiculobullous
diseases, such as pemphigus vulgaris, bullous pemphigoid or paraneoplastic
pemphigus, urticaria, SJS, or a fixed drug eruption. The distinguishing features be-
tween different types of vesiculobullous lesions are described in Table 5.

TREATMENT

Treatment of EM varies according to disease severity. The clinical course of an

episode of EM is variable. Complete healing of lesions may take up to 3 to 6 weeks
and the disease may recur.

Identification and Treatment of Precipitating Factors

No treatment has been identified that predictably alters the clinical course of EM. HSV-
induced EM occurs an average of 8 days after the development of HSV infection, at a
time when treatment solely for HSV infection is no longer indicated. In general, treat-
ment should be instituted as appropriate for management of an active viral infection.
Any drug suspected to have precipitated EM should be promptly discontinued.
Table 4
Clinical features of EM subgroups, and SJS and TEN

Site of Involvement Etiology Clinical Manifestations Demographic Prodromal Signs

EM Minor Skin Infectious in Skin Young adult Rare
 Less than 10% of BSA origin  Symmetric distribution (20–40 y)
Mucosa  Predilection for the Slightly more in
 Uncommon extensor surfaces of the extremities women
 Most commonly oral  Circular asymptomatic than men
mucosa; vermilion border, lip erythematous plaques in a concen-
mucosa, gingiva and palate tric array 2–20 mm in size
Note: Occasionally EM minor is  Negative Nikolsky’s sign
isolated to the oral mucosa  Transient hypo or
without skin involvement hyperpigmentation at lesion sites
Mucosa
 Painful, hemorrhagic,
superficial ulcerations
 Heal without scar
Note: complete recovery in 1–4 wk
EM Major Skin Infectious in Skin Young adult Usually absent but
 Less than 10% of BSA origin  Symmetric distribution (20–40 y) in some patients mild
Mucosa  Predilection for the extensor sur- systemic symptom such
2 different mucosal site faces of the extremities as fever or chills
 Most common site is oral  Circular asymptomatic
mucosa followed by buccal/labial erythematous plaques in a
mucosa concentric
 Less frequently the floor of the  Negative Nikolsky’s sign

Erythema Multiforme
mouth, palate and gingival are Mucosa
involved  Larger than EM minor
 Heal without scarring
 Multiple painful papules,
vesicles and widespread ulcerations
Note: complete recovery in 1–6 wk

(continued on next page)

591
 592
Table 4
(continued )

Samim et al
Site of Involvement Etiology Clinical Manifestations Demographic Prodromal Signs
SJS Skin Drugs Skin Children 15 y; Fever, pharyngitis, headache,
 Less than 10% of BSA  Atypical flat adults myalgia, arthralgia (flulike
Mucosa target-initially a macular, Male/Asian symptoms)
2 different mucosal sites (oral morbilliform rash on the face, neck,
mucosal lesions always) chin, and central trunk
 Sudden onset erosion of oral,  Widespread blistering-positive
genital and/or conjunctival Nikolsky’s sign
mucosa  Scarring may occur
 Buccal mucosa, palate and Mucosa
vermillion border of lip  Painful extensive
 Oral lesion sometimes precede irregular hemorrhagic erosions with
skin involvement greyish-white pseudomembranes
 Hemorrhagic crusts on lip
Note: complete recovery in 2–6 wk
SJS/TEN Skin Drugs  Same as SJS Same as SJS Flulike symptoms
 10%–30% of BSA  Always with systemic symptoms
Mucosa
 Same as SJS
TEN Skin Drugs Skin Older adults Severe sudden-onset flulike
 >30% of BSA  Widespread purpuric Female/regional symptoms
Mucosa macules or flat atypical target, differences
 Severe involvement of many widespread erythema and
mucosal surfaces, including oral epidermal necrolysis
mucosa  Bulbar conjunctiva
 Positive Nikolsky’s sign
 Scarring
Mucosa
 Painful crusts and erosions
 Swelling of tongue
Note: variable recovery rate;
hospitalization required; poor
prognosis; mortality 30%–40%

Abbreviations: BSA, body surface area; EM, erythema multiforme; SJS, Stevens-Johnson syndrome; TEN, toxic epidermal necrolysis.
 Erythema Multiforme 593

Table 5
Description of typical clinical features and distinguishing features to differentiate erythema
multiforme from other vesiculo-bullous lesions

Clinical Features Distinguishing Features

Primary herpetic Usually seen among children Multiple punctuate ulcerations
gingivostomatitis under 5 y of age; present with that coalesce to form larger
multiple painful oral ulcers irregular painful ulcerations;
preceded by vesicles; fever and mainly in children; and do not
general malaise usually present with skin rash
Pemphigus vulgaris Multiple shallow irregular and EM is acute with target lesions; no
painful ulcers proceeded by presence of antibodies against
vesicles or bullae; occurs in desmoglein in EM; direct
middle age; positive Nikolsky’s immunofluorescence shows
sign; presents as a chronic “fish-net” appearance
disease with periods of
remission or exacerbation;
cutaneous and oral lesions may
be seen
Bullous Chronic condition; presents with EM is acute with target lesions; no
pemphigoid large bullae or vesicles antibodies detected with
intraorally; ocular and other immunofluorescence
mucous membranes may be
involved; histologically, a
suprabasilar split separating the
epithelium and the connective
tissue is seen
Paraneoplastic Chronic disease that has EM is acute; not usually associated
pemphigus polymorphous progressive skin with malignancy;
lesions; severe mucosal immunofluorescence
involvement; presence of microscopy does not show any
underlying malignancy; cell-surface IgG deposition or
conjunctiva involvement combined cell surface and
basement membrane zone IgG
and C3 deposition
Urticaria Transient plaques with central Lack of the central zone typically
zone of normal skin or seen in EM; individual lesions
erythema; may have associated tend to last no more than 24 h
mucosal edema
Fixed drug eruption Single or multiple erythematous The medication history typically
plaques with or without central reveals temporal trends of oral
necrosis; less mucosal lesions associated with
involvement medication

Abbreviations: EM, erythema multiforme; Ig, immunoglobulin.

Treatment of Mild EM
Treatment of mild disease (limited oral and cutaneous involvement), should be
focused on symptomatic relief using topical anti-inflammatory, anesthetic, or anal-
gesic agents. Some of the drugs that can be used are as follows:
 Fluocinonide 0.05% or other topical steroid agents need to be applied to involved
areas 2 to 3 times per day
 Mouthwash containing equal parts of viscous lidocaine 2%, diphenhydramine
(12.5 mg/5 mL), and an aluminum hydroxide and magnesium hydroxide mixture
(Maalox) as a swish-and-spit, up to 4 times per day.
594 Samim et al

Treatment of Severe EM
In the severe form of EM, there may be extensive lesions and inability to ingest foods.
Systemic steroids may be advised in consultation with a physician depending on the
etiology and severity of disease. The most commonly used steroid is prednisone 40 to
60 mg per day, which is tapered over 2 to 4 weeks. However, in some cases, systemic
steroid use only partially suppresses disease activity and may increase the risk of dis-
ease chronicity and prolonged duration of attacks.32

Recurrence and Supportive Care

Depending on the case, recurrence of EM should be avoided by providing antiviral
therapy or immunosuppressive therapy. Continuous antiviral therapy is effective for
the prevention of recurrent HSV-associated EM. A 6-month trial of either acyclovir
(400 mg twice daily), valacyclovir (500 mg twice daily), or famciclovir (250 mg twice
daily) has been suggested. Supportive care should be provided in the form of a liquid
diet, intravenous fluids, electrolytes, and nutritional support.

Other Treatments
Other recommended treatment for patients with severe recurrent EM who fail to
respond to continuous systemic antiviral therapy are azathioprine (100 to 150 mg/d
or 2 mg/kg/d in patients with normal thiopurine methyltransferase activity), mycophe-
nolate mofetil (1000 mg twice daily), or dapsone (100 to 200 mg/d). Data regarding the
usefulness of these medications are limited.

SUMMARY

EM is a widespread hypersensitivity reaction that occurs with varying degrees of

severity. HSV infection is the most common precipitator of EM, and the possibility
of HSV-induced disease should be considered in all patients. The history of lesion
eruption and related clinical findings provides the most important information for the
diagnosis of EM. Patients should be queried regarding prodromal symptoms as well
as recent introduction of any new medications. The clinical course of EM is usually
self-limiting, resolving within weeks without significant sequelae. However, in a minor-
ity of cases, the disease recurs frequently over the course of years. Most patients with
EM can be managed with symptomatic therapy alone. However, patients with severe
EM may require hospitalization for hydration, analgesia, antiviral therapy, and sys-
temic steroids.

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