• Wednesday July 15,2020

Erythema exudative multiforme

Erythema exudative multiforme (EEM) is an inflammatory rash on the skin or mucosa. Due to the visual similarity of the rosette-shaped herring with military cockades, erythema exudativum multifome is also referred to as cockroach erythema and the foci as gunshot lesions.

What is erythema exsudativum multiforme?

Erythema exudativum multiforme is often surprising to the patient. Suddenly, a rash of patches, papules, wheals or blisters forms on the skin, at the level of the skin, somewhat raised or deepened into the skin.
© Neokryuger - stock.adobe.com

In Ertyhema exsudativum multiforme, skin lesions develop on the patient's skin, often with a purple center surrounded by a bluish halo. In between, a pale ring is visible, as in a cockade or target. Often the flocks look like coins lying side by side, individually or in groups.

There are two different forms in severity and course. In the light form, the EEM Minor, the patients usually do not feel sick. The kokarden-shaped foci are found mainly on the skin of the back of the hand and the extension side of the forearm. There is no or only slight blistering, the mucous membranes are not affected.

In severe severity (EEM Major), the general condition of the patient is impaired. The entire body, including the feet, palms and oral mucosa, may be affected by rashes, blisters have formed in the middle of the flock.

The transition to Stevens-Johnson syndrome is fluid, a variant of the EEM major with severe skin involvement throughout the body. Here the mucous membranes on the mouth, eyes or genitals are affected. The risk of secondary infection is high, and scars often remain after healing of the erythema.


Many erythema exudative multiforme diseases follow infection with herpes simplex virus. It is believed that fragments of the herpes simplex DNA cause a cell-damaging reaction in cells of the epidermis. However, this is rare relative to the total number of herpes simplex infections. Therefore, a genetic predisposition is assumed.

Other viral or bacterial infections, mycoses, vaccines, preservatives or certain medications are listed among the causes. Antibiotics, so-called hydantoins (partly contained in antiepileptic drugs) or pyrazolones (partly contained in painkillers) are suspected, inter alia, of causing erythema exsudativum multiforme.

With the EEM Minor form, the trigger can not be determined in 60 percent of the cases. If the cause is the herpes simplex virus, a chronic form with relapsing episodes can develop. By contrast, EEM Major is a one-time disease - almost always drug-induced, due to cytotoxic side effects (cytotoxic reaction).

Symptoms, complaints & signs

Erythema exudativum multiforme is often surprising to the patient. Suddenly, a rash of patches, papules, wheals or blisters forms on the skin, at the level of the skin, somewhat raised or deepened into the skin. The lesions are reminiscent of cockades or target discs with a purple center and blue outer ring.

In the major form, the rash often spreads from the extremities to the trunk. Also in the mouth area, vesicles on the palate and gums or shooting disc lesions on the lips are noticeable. The rash can cause itching.

Anyone who has an infection with herpes simplex virus behind, first observed a fiber blister on the lips and then finds a strong itchy rash on the arms and legs, should see the doctor. Stevens-Johnson syndrome includes fever, enlarged lymph nodes, liver and spleen.

The mucous membranes are always affected, often accompanied by catarrh-like symptoms. The variants in the skin symptoms range from a few target lesions to large-scale, scarlet exanthema.

Diagnosis & History

The diagnosis is usually made according to the clinical picture. The history takes into account overcome infections or mycoses, but also medication intake and their temporal relationship.

Without significant harbingers, a rash forms on the extremities or whole body. The reddish papules initially measure 0.1 to 0.3 centimeters. Within 24 hours, they expand into gun-shaped cockades, in the Major form with central bubbles.

Exanthema can affect the back of the hand, palms and soles of the feet, appearing on the neck, face, neck, or on the extensor sides of the arms and manifesting in groups of elbows or knees. In about 50 percent of cases there is mild (usually oral) mucosal involvement on the lips, cheeks and tongue. Joint swelling and pain can occur.

With the major form the general condition is clearly limited. Histological examinations are not conclusive, the laboratory usually inconspicuous, occasionally increased inflammation, including eosinophilia.


Erythema exudativum multiforme often develops after an infectious disease and manifests itself as an inflammatory skin rash that can affect the mucous membranes. The cause of the symptom is considered to be a drug reaction, a tumor attack, the outbreak of a herpes simplex virus and infection by bacteria or streptococci capable of reproduction.

Surprisingly, the person affected tends to have blister-like wheals, which form an annular bluish skin reaction, the center of which shows a strong purple color. The visible appearance is referred to as a shooting target. As the disease progresses, different sized, highly itchy foci develop.

Erythema exsudativum multiforme is divided into major and minor forms. Patients should therefore immediately seek medical assistance at the first sign, especially if a herpes simplex virus broke out before. If medical therapy is not initiated early, the complications accumulate and become chronic.

The symptom affects the entire body and manifests on the mucous membranes. In the further course scars form by scratching the skin. Fever episodes and enlargements of the liver, spleen and lymph nodes are added and there is a smooth transition into the so-called Stevens-Johnson syndrome.

Depending on the causative agent of erythema exsudativum multiforme, various countermeasures in the form of anti-inflammatory glucocorticoids as well as skin lotions and mouthwashes are prescribed for medical treatment.

When should you go to the doctor?

Rash should always be medically examined and treated. If the affected regions spread or increase in intensity, a visit to a doctor is recommended. If, as a result of the skin changes, the general locomotion can no longer take place as usual, a doctor should be consulted.

If it comes to incorrect posture of the body or pain of the muscles by a misalignment, a doctor is needed. Without correction, permanent damage to the skeletal system is imminent. If, due to the discomfort of the hands, objects can no longer be held as usual or if the overall performance limit drops, it is advisable to consult a doctor.

Changes in the mucous membranes in the mouth or open wounds require a visit to the doctor. Germs can enter the organism and lead to new diseases. Put fever; Dizziness or nausea, a doctor is needed. If swelling or skin discoloration occurs, a doctor should examine the affected areas and provide medical care.

If the eyes and also the genitals are affected, the complaints should be clarified by a doctor. If changes in vision occur or psychological problems arise, a doctor is needed. Blistering on the skin for no apparent reason is considered unusual and should be investigated.

Treatment & Therapy

EEM is an acute self-limited disease and the skin lesions heal on their own within two weeks. Treatment is limited to symptomatic therapy.

Good experiences were made with the external treatment of the skin lesions with Lotio alba, a shaking mixture of aqueous zinc oxide. Joint swelling is combated with cool envelopes or pads or a local antihistamine.

Glucocorticoid-containing creams such as 0.1 percent triamcinolone cream or 0.05 to 1 percent betamethasone emulsion can help against irritating itching. For lesions of the oral mucosa, oral rinses with chamomile extract bring relief.

Systemic glucocorticoids such as prednisone can be prescribed for the intensive treatment of the affected mucous membranes in the more severe major form. Also, antibiotic supplements for the prevention of secondary infections may be advisable. For stronger itching oral antihistamines such as desloratadine or cetirizine can be used.

Outlook & Forecast

The erythema exudative multiforme has a favorable prognosis. The changes in the appearance of the skin occur acutely and thus trigger the impression of a serious disorder. Ultimately, however, the symptoms completely disappear within a few weeks. Most patients are symptom free after less than fourteen days.

In addition, they need no medical support for the relief of the complaints, since the organism regenerates itself. If there are no complications due to itching or visual blemishes, the healing process can be short-lived and without medical treatment.

Unfavorable is the overall prognosis as soon as further illnesses are present. In many cases, erythema exudativum multiforme is a concomitant of another disease. Although the skin changes regress without any external influence or the administration of medication, there are often complex diseases that need to be treated.

The prognosis of these diseases is often unfavorable or lengthy. The weaker the immune system of the patient is due to the underlying disease, the more likely delays in the healing process of the erythema exudative multiforme.

In addition, the risk of complications is increased. In open wounds, pathogens can enter the organism and trigger sepsis. There is a potential risk to life. Fever bouts are also possible. They temporarily weaken the patient additionally.


If a triggering substance could be established beyond doubt, it is enough for the patient to avoid it in the future in order to prevent a recurrence of EEM. In patients with frequent recurrences due to the herpes simplex virus, suppressive antiviral therapy can help - either for a short time or as a long-term therapy, for example with acyclovir.


In the case of erythema exsudativum multiforme, in most cases, the person concerned has no special or direct measures and options for follow-up care. In the case of this disease, the person concerned is primarily dependent on rapid and early treatment and diagnosis so that the symptoms do not worsen further. As a rule, it can not come to an independent healing, so a visit to a doctor is always necessary.

The affected person should definitely relax with Erythema exsudativum multiforme and protect his body. Here is to be foreseen from efforts or other stressful and physical activities, so that there are no further complications. The person affected should also take the medication prescribed by the doctor regularly and in the correct dosage.

The doctor should then be consulted when it comes to questions or other ambiguities. Also, regular examinations of the inflammation by a doctor are important in order to always monitor the current status and control. Successful treatment of erythema exudativum multiforme will generally not reduce life expectancy. No further follow-up measures are necessary.

You can do that yourself

EEM is an acute illness that must first be clarified by a doctor. The treatment can be supported by those affected through various measures.

If it is suspected that a drug is responsible for the erythema exudativum multiforme, the responsible preparation must be discontinued. Patients should talk to the responsible doctor. The skin lesions must always be treated with medicinal drugs. Sometimes the antihistamines used can be supplemented with cooling envelopes.

Cooling of the joints, especially in the form of coils, cooling sprays or envelopes, is particularly helpful. However, the use of appropriate means must be discussed in advance with a doctor in order to avoid adverse events. In the case of the severe major form, a medical treatment is required in any case.

Those affected can support the therapy by protecting the mucous membranes. Dietetic measures such as a diet that does not contain spicy, sour or overly hot foods and the absence of luxury foods such as coffee or alcohol are recommended. If the symptoms persist despite all measures or even increase in intensity, a doctor must be consulted. Maybe the erythema exsudativum multiforme is based on a serious condition that needs to be diagnosed and treated.

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