1. 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?

2. ERYTHEMA MULTIFORME

3. 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%

4. 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

5. 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

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

7. 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

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

9. 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

10. 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

11. 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

12. 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

13. 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