Erythema multiformeMANAGEMENT

DERMATOLOGY PRESENTATIONS · 12 SECTIONS

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529 items

☷ Legend

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Cardiovascular Presentations71▾

Respiratory Presentations52▾

Neurological Presentations83▾

Gastrointestinal Presentations74▾

Genitourinary and Reproductive Presentations48▾

Infectious Disease Presentations148▾

Trauma Presentations89▾

Toxicologic Presentations80▾

Psychiatric Presentations26▾

Musculoskeletal and Rheumatologic Presentations96▾

Dermatology Presentations23▾

Allergic contact dermatitis Bullous Pemphigoid Cutaneous Abscess DRESS syndrome Eczema Herpeticum Erysipelas Erythema multiforme Henoch-Schönlein purpura Herpes Zoster (Shingles)Herpetic Whitlow Hidradenitis suppurativa Paronychia Pediculosis (Lice)Pemphigus Vulgaris Pilonidal Abscess Pressure injury Psoriasis (acute flare)Psoriasis Flare Staphylococcal Scalded Skin Syndrome Stevens-Johnson Syndrome (SJS)Toxic Epidermal Necrolysis (TEN)Urticaria (acute)Warfarin-induced Skin Necrosis

Environmental and Exposure Presentations27▾

Hematologic and Oncologic Presentations36▾

Pediatric-Specific Presentations19▾

Endocrine and Metabolic Presentations45▾

ENT and Maxillofacial Presentations27▾

Ophthalmologic Presentations19▾

Obstetric Presentations23▾

Systemic and Miscellaneous Presentations17▾

01Approach to the Critical Patient/attcp97

Immediate threats

›Instability screen

›Airway risk

›Oropharyngeal mucosal sloughing

›Stridor

›Voice change

›Drooling

›Breathing risk

›Hypoxia

›Tachypnea

›Suspected pneumonia

›Circulatory risk

›Hypotension

›Shock physiology

›Sepsis concern

›High-risk phenotype

›Epidermal detachment

›Detachment with pain out of proportion

›Positive Nikolsky sign

›Ocular involvement

›Photophobia

›Vision change

›Severe mucosal involvement

›Oral intake failure

›Urinary retention or dysuria

›Escalation triggers

›If airway compromise, activate airway team

›If shock, resuscitation bay and sepsis pathway

02History/hx48

Core symptom pattern

›Timeline and evolution

›Onset time

›Hours to days progression

›Recurrent episodes pattern

›Prodrome

›Fever

›Malaise

›Upper respiratory symptoms

›Lesion evolution

›Fixed lesions lasting days

›New crops

›Skin symptom quality

›Pruritus

›Pain or burning

›Tenderness suggesting SJS/TEN

›Mucosal symptoms

›Oral pain

›Odynophagia

›Eye irritation

›Dysuria

›Genital pain

Triggers and exposures

›Infection associations

›Herpes simplex virus

›Recent oral or genital herpes

›Recurrent HSV pattern preceding rash

›Mycoplasma pneumoniae

03Physical Exam/exam48

Skin examination

›Morphology and distribution

›Target lesions

›Typical targets present

›Atypical targets predominance

›Distribution

›Acral predominance

›Trunk involvement extent

›Palms and soles

›Lesions present

›Severity markers

›Body surface area estimation

›Percent involvement

›Percent epidermal detachment

›Skin tenderness

›Disproportionate pain flag

›Nikolsky sign

›Positive suggests SJS/TEN spectrum

›Secondary infection signs

›Purulence

›Cellulitis

›Fever with focal skin infection

Mucosal and organ system examination

›Oral cavity

›Erosions

›Hemorrhagic crusted lips

›Hydration signs

›Dry mucosa

04Differential Diagnosis/ddx43

Life-threatening and must-not-miss

›Severe mucocutaneous syndromes

›Stevens-Johnson syndrome (ICD-10 L51.1)

›Atypical targets

›Epidermal detachment under 10 percent

›Toxic epidermal necrolysis (ICD-10 L51.2)

›Epidermal detachment over 30 percent

›SJS-TEN overlap

›Detachment 10 to 30 percent

›Drug reaction with eosinophilia and systemic symptoms

›Facial edema

›Eosinophilia

›Hepatitis

›Invasive infection mimics

›Meningococcemia

›Petechiae or purpura

›Shock physiology

›Disseminated gonococcal infection

›Tenosynovitis

›Migratory polyarthralgia

›Staphylococcal scalded skin syndrome

›Superficial desquamation

›Pediatric predominance

Common mimics

›Urticaria

›Transient lesions under 24 hours

›Dermatographism

›Fixed drug eruption

05Laboratory Tests/lt31

Baseline severity and alternative diagnosis

›Core labs for moderate to severe phenotype

›Complete blood count

›Leukocytosis for infection

›Eosinophilia for drug hypersensitivity patterns

›Electrolytes and creatinine

›Dehydration assessment

›Acute kidney injury flag

›Liver enzymes

›Drug reaction systemic involvement screen

›C-reactive protein

›Inflammatory burden trend support

›Infection-directed testing when indicated

›HSV testing support

›Lesion PCR when vesicles present

›Serology limited utility for acute trigger timing

›Mycoplasma pneumoniae evaluation

›Respiratory PCR based on local availability

›Serology timing limitations

›Blood cultures

›Fever with systemic toxicity

›Sepsis concern

Treatment safety monitoring

›Medication monitoring triggers

›If systemic corticosteroids used

›Glucose monitoring

›Infection reassessment

›If antivirals used

06Diagnostic Tests/dt42

Scoring Systems

›SJS/TEN risk stratification when detachment present

›SCORTEN

›Age over 40 years

›Malignancy

›Heart rate over 120 per minute

›Initial epidermal detachment over 10 percent

›Serum urea elevation

›Serum glucose elevation

›Serum bicarbonate reduction

›ABCD-10

›Age

›Bicarbonate

›Cancer

›Dialysis

›Detachment over 10 percent

MRI

›MRI role

›Typically not indicated for EM diagnosis

›Consider only for alternative diagnosis workup

›CNS symptoms prompting separate pathway

›Deep tissue infection concern prompting separate pathway

›CT role

›Typically not indicated for EM diagnosis

›Consider CT chest when severe respiratory symptoms with alternative diagnosis concern

›Complicated pneumonia concern

›Pulmonary embolism concern with separate criteria

07Disposition/dispo31

Admission and transfer criteria

›Admission indications

›Oral intake failure

›Dehydration

›Intractable pain limiting intake

›Significant mucosal involvement

›Oral

›Ocular

›Genital

›Diagnostic uncertainty with SJS/TEN possibility

›Skin tenderness

›Positive Nikolsky sign

›Epidermal detachment

›Immunocompromised status

›Sepsis concern

›Transfer indications

›Epidermal detachment

›Burn center consult pathway

›Severe ocular involvement

›Ophthalmology capability requirement

Discharge criteria

›Discharge safety checklist

›Hemodynamic stability

›No progressive mucosal disease

›Adequate oral intake plan

›Pain controlled with oral regimen

›Clear trigger plan

›Suspected medication avoidance documented

08Treatment/t94

Trigger removal and general measures

›Trigger management

›Suspected culprit medication discontinuation

›Drug exposure within prior 1 to 3 weeks

›Re-exposure history

›Infection management targeting likely cause

›HSV-associated recurrent EM pathway

›Suspected Mycoplasma pneumoniae pathway

›Symptom control

›Skin care

›Bland emollients

›Cool compresses

›Pruritus control

›Oral non-sedating antihistamine

›Cetirizine 10 mg PO daily

›If inadequate, increase to 20 mg PO daily

›Sedation monitoring

›Alternative

›Fexofenadine 180 mg PO daily

›If inadequate, increase to 180 mg PO twice daily

›Pain control

›Acetaminophen PO

›1000 mg PO every 6 hours as needed

›Maximum 4000 mg per day

›If severe pain, opioid short course

›Hydromorphone 1 to 2 mg PO every 4 to 6 hours as needed

›Sedation and constipation plan

Topical therapy

›Cutaneous inflammation control

›Topical corticosteroid for localized lesions

›Triamcinolone 0.1 percent ointment

›Apply thin layer twice daily for 7 to 14 days

›Avoid face and intertriginous areas

›Lower potency option for face

›Hydrocortisone 1 percent

›Apply thin layer twice daily for up to 7 days

›Oral mucositis supportive care

›Topical anesthetic

›Lidocaine viscous 2 percent

›Swish and spit 5 to 10 mL every 4 to 6 hours as needed

›Aspiration risk counseling

›Oral hygiene measures

›Saline rinses

›Soft diet

Antiviral therapy for HSV-associated EM

›Acute HSV treatment when active lesions or strong HSV trigger

›Valacyclovir PO

›1000 mg PO twice daily for 7 to 10 days

›If creatinine impairment, dose adjustment

›Alternative

›Acyclovir PO

›400 mg PO three times daily for 7 to 10 days

›If creatinine impairment, dose adjustment

›Suppressive therapy for recurrent HSV-associated EM

›Valacyclovir PO

›500 mg PO daily

›If frequent breakthroughs, 500 mg PO twice daily

›Trial duration 6 to 12 months

›Alternative

›Acyclovir PO

›400 mg PO twice daily

›Trial duration 6 to 12 months

Systemic therapy considerations

›Systemic corticosteroids

›Limited evidence for routine EM minor

›Prefer supportive care first

›If severe EM major with disabling mucositis and dermatology involvement

›Prednisone PO

›0.5 mg per kg per day

›Typical adult maximum 60 mg per day

›Taper plan over 7 to 14 days

›Infection risk reassessment

›Fever monitoring

›Worsening skin tenderness monitoring

›SJS/TEN pathway exclusion requirement before immunomodulators

›If any epidermal detachment, manage as SJS/TEN until proven otherwise

›Specialized therapy decisions

›Dermatology

›Burn unit or ICU

Suspected Mycoplasma pneumoniae-associated mucositis

›Respiratory infection management when clinical pneumonia

›Macrolide option

›Azithromycin PO

›500 mg PO once then 250 mg PO daily for 4 days

›QT risk screening

›Alternative option

›Doxycycline PO

›100 mg PO twice daily for 7 to 10 days

›Pregnancy avoidance

Ocular involvement

›Eye protection steps

›Preservative-free artificial tears

›1 to 2 drops every 2 to 4 hours

›If conjunctivitis or epithelial defect, urgent ophthalmology

›Topical antibiotic decisions by ophthalmology

›Symblepharon prevention strategies by ophthalmology

Evidence and guideline framing

›Expert consensus framing

›Immediate discontinuation of suspected culprit drug for severe mucocutaneous reactions (Class I consensus)

›Early dermatology and ophthalmology involvement for mucosal disease (Class I consensus)

›Antiviral suppression for recurrent HSV-associated EM (Class IIa consensus)

09Special Populations/sp26

Pregnancy

›Pregnancy-specific considerations

›Trigger profiling

›Medication exposure review

›Infection screening threshold lower

›Medication safety

›Avoid doxycycline

›Valacyclovir acceptable when indicated

›Disposition threshold

›Lower threshold for admission with poor intake

Geriatric

›Older adult considerations

›Polypharmacy risk

›Higher probability of drug-triggered severe reactions

›Dehydration vulnerability

›Lower reserve with mucositis

›Renal dosing

›Antiviral dose adjustment need

Pediatrics

›Pediatric considerations

›Common triggers

›HSV

›Mycoplasma pneumoniae

›Weight-based dosing

›Acyclovir dosing per kg with pediatric references

›Avoid adult fixed dosing without weight check

›Admission threshold lower

›Oral intake risk

10Background/b30

Epidemiology

›Frequency patterns

›EM often infection-associated

›HSV most common trigger in recurrent EM

›Mycoplasma pneumoniae associated in some cases

›Drug-triggered EM less common than drug-triggered SJS/TEN

›Typical demographics

›Any age

›Recurrent cases often younger patients

Pathophysiology

›Immunologic mechanism

›Cell-mediated hypersensitivity pattern

›Interface dermatitis

›Keratinocyte injury

›HSV-associated pathway concept

›Viral antigen driven immune response

›Clinical consequence mapping

›Target lesion formation

›Central necrosis and inflammation pattern

›Mucosal erosions

›Epithelial injury and inflammation

Therapeutic Considerations

›Supportive care rationale

›Self-limited course common in EM minor

›Symptom control improves intake and comfort

›Antiviral rationale

›HSV suppression reduces recurrence frequency in HSV-associated recurrent EM

›Corticosteroid rationale and caution

11Patient Discharge Instructions/pdi26

copy discharge instructions

›Home care plan

›Skin care

›Fragrance-free moisturizer multiple times daily

›Cool compresses for discomfort

›Itch and pain plan

›Cetirizine as directed

›Acetaminophen as directed

›Mouth care if sores

›Saline rinses

›Soft foods and fluids

›Medication safety plan

›Avoid suspected trigger medication

›Provide medication list to every clinician until clarified

›Follow-up plan

›Primary care within 48 to 72 hours

›Dermatology referral if recurrent, severe, or uncertain diagnosis

›Ophthalmology follow-up if any eye symptoms

›Return immediately for red flags

›Trouble breathing

›Trouble swallowing or drooling

›Rapidly spreading rash

›Skin pain or tenderness worsening

›Blistering or skin peeling

›Eye pain, light sensitivity, or vision change

›Unable to drink enough fluids or decreased urination

›Fever with feeling very unwell

12References/r13

Clinical guidelines and evidence sources

›Source list

›Dermatology and emergency medicine reviews on erythema multiforme and SJS/TEN differentiation

›Target lesion morphology definitions

›Management emphasis on supportive care and trigger treatment

›HSV-associated recurrent EM antiviral suppression evidence summaries

›Valacyclovir and acyclovir suppressive regimens

›Recurrence reduction outcomes in recurrent EM cohorts

›Severe cutaneous adverse reaction resources

›SCORTEN prognostic tool for SJS/TEN

›Burn unit level care standards for epidermal detachment

›Clinical management system formatting specification

›Checkbox-only formatting rules

›Section structure requirements

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Reviewed by SymptomDx Medical Team · Last reviewed August 18, 2026

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