Do we need to distinguish kung EM Minor or Major ung patient? 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?

ERYTHEMA MULTIFORME

Erythema Multiforme EM 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%

EM Minor Characteristic & Evolution of the Lesion Periphery: ring of erythema Central: flatters, more pruritic and dusky “target” or “iris” lesion with three zones Central dusky purpura Elevated, edematous, pale ring Surrounding macular erythema

EM Minor Sites of Predilection Age of Predilection (Symmetrical and acral) (Best observed on) Palms and soles Dorsal feet Extensor limbs Elbows Knees Age of Predilection young adults

Erythema Multiforme Steven-Johnson syndrome / EM major Clinically different from minor Frequently, febrile prodrome

EM Major Characteristic & Evolution of the Lesion Flat, erythematous or purpuric macules incomplete “atypical targets” (may blister centrally Larger and more commonly confluent lesions compared to EM minor

EM Major Sites of Predilection Begins diffusely on the trunk and mucous membranes Spreads centripetally Age of Predilection Eruption occurs at all ages

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

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

Hence, there is a genetic component for both diseases 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

Disease Diagnosis Physical examination Characteristic Target Lesions Distribution- symmetrical and acral Evolution: Center becomes darker and purpuric Lesions flatten at the center Ring of Erythema

Salient Features Erythema Multiforme EM Minor: Young adults EM 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 centers 5 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