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
›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
›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)