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6. Erythema Multiforme Classification and Immunopathogenesis

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6. Erythema Multiforme Classification and Immunopathogenesis Bajaj P et al. Erythema Multiforme. Review Article Erythema Multiforme: Classification and Immunopathogenesis Puneet Bajaj, Robin Sabharwal, Rajesh Mohammed PK, Deepti Garg, Charu Kapoor Department of Oral Pathology and Microbiology, Bhojia Dental College and Hospital, Solan Corresponding Author: Abstract: Erythema multiforme is a skin condition considered to be a hypersensitivity reaction to Dr. Puneet Bajaj infections or drugs. It consists of a polymorphous eruption of macules, papules, and characteristic Professor & HOD, “target” lesions that are symmetrically distributed Department of Oral Pathology with a propensity for the distal extremities. There is minimal mucosal involvement. Erythema multiforme Bhojia Dental College and Hospital, can be triggered by a range of factors, but more Solan, Himachal Pardesh, India. commonly it is associated with herpes simplex virus (HSV). Most other cases are initiated by drugs. The Contact Number: +91 9814278407 clinical classification of these disorders has often been variable, thus making definitive diagnosis sometimes Email: [email protected] difficult. The present article reviews the classification and highlights the associated potential etiologic Received: 01-09-2013 agents, pathogenic mechanisms and treatment of Erythema multiforme. Revised: 01-10-2013 Keywords: Erythema multiforme, Target lesions, Accepted: 12-10-2013 TEN This article may be cited as: Bajaj P, Sabharwal R, PK Mohammed R, Garg D, Kapoor C. Erythema Multiforme: Classification and Immunopathogenesis. J Adv Med Dent Scie 2013;1(2):40-47. Introduction: Erythema multiforme (EM) is a typically exanthematous, cutaneous variant with mild, self-limiting, and recurring minimal oral involvement (EM minor) to a mucocutaneous reaction characterized by progressive, fulminating, severe variant with target or iris lesions of the skin and mucous extensive mucocutaneous epithelial necrosis membranes. 1 (Stevens-Johnson syndrome: SJS; and toxic EM usually affects apparently healthy young epidermal necrolysis: TEN). All variants adults and the peak age at presentation is share two common features: typical or less 20–40 years although as many as 20% of typical cutaneous target lesions and satellite cases are children. 2 cell or more widespread necrosis of the Erythema multiforme is a reactive epithelium. These features are considered to mucocutaneous disorder that comprises be sequelae of a cytotoxic immunologic variants ranging from a self-limited, mild, 40 Bajaj P et al. Erythema Multiforme. attack on keratinocytes expressing non-self- cell mediated immune reaction to the antigens. 3 precipitating agent. The pathogenesis of herpes-associated Erythema multiforme is Immunopathogenesis: Erythema multiforme is probably an consistent with a delayed-type immunologically mediated process. It is hypersensitivity reaction. The disease begins considered to be a hypersensitivity reaction with the transport of viral DNA fragments to associated with certain infections and distant skin sites by peripheral blood medications. mononuclear cells. HSV genes within DNA fragments are expressed on keratinocytes, • Infections leading to the recruitment of HSV-specific V Herpes simplex virus 1 and 2 CD4+ TH1 cells (helper T cells involved in Herpes simplex virus (HSV) is the cell-mediated immunity). The CD4+ cells most commonly identified etiology respond to viral antigens with production of of this hypersensitivity reaction. interferon-γ, initiating an inflammatory V Mycoplasma pneumoniae cascade. This cytokine then amplifies the V Fungal infections immune response and stimulates the • Medications production of additional cytokines and V Barbiturates chemokines, which aids the recruitment of V Hydantoins further reactive T cells to the area. These V Non-steroidal anti-inflammatory cytotoxic T cells, NK cells or chemokines drugs can all induce epithelial damage (Figure I). V Penicillins Drug-associated erythema multiforme V Phenothiazines lesions test positive for tumor necrosis factor V Sulfonamides α and not interferon-γ as in herpes Erythema multiforme is also associated with associated erythema multiforme lesions, Vaccines (diphtheria-tetanus, hepatitis B,14 suggesting a varying mechanism. 1 smallpox) and appears to be the result of a Figure I: Pathogenesis of Erythema Multiforme Much of the tissue damage in drug-induced SJS, there is some evidence for a Fas–FasL lesions appears to be due to apoptosis and, interaction. FasL mediates apoptotic cell because of the paucity of the inflammatory death by binding to Fas on cells and reaction. However, particularly in TEN and inducing the formation of caspases. Fas is 41 Bajaj P et al. Erythema Multiforme. present on keratinocytes and FasL is found • Bullous erythema multiforme, on activated T cells and NK cells and thus detachment below 10% of the body binding of keratinocytes to T cells or NK surface area plus localized "typical cells can induce apoptosis. 4,5 targets" or "raised atypical targets"; • Stevens-Johnson syndrome, Clinical features The presentation of EM ranges from a self- detachment below 10% of the body surface area plus widespread limited, mild, exanthematous variant with minimal oral involvement (EM minor) to a erythematous or purpuric macules or flat progressive, fulminating, severe variant with atypical targets; • extensive mucocutaneous epithelial necrosis Overlap Stevens-Johnson syndrome - toxic epidermal necrolysis, detachment (Stevens–Johnson syndrome), with EM major intermediate in severity. between 10% and 30% of the body surface area plus widespread The current classification of EM and related disorders is based upon the presence, purpuric macules or flat atypical targets; morphology, and extent of cutaneous and • Toxic epidermal necrolysis with spots, mucosal disease. The cutaneous lesions of detachment above 30% of the body erythema multiforme comprise typical surface area plus widespread purpuric targets, raised atypical targets, flat atypical macules or flat atypical targets; • targets, and macules with or without blisters. Toxicepidermal necrolysis without spots, A summary of types and clinical features is detachment above 10% of the body presented in (Table I and II).6 surface area with large epidermal sheets The following consensus classification in and without any purpuric macule or five categories was proposed: target. Extent of Clinical type Patterns of lesions Distribution blisters/ detachment,% Erythema multiforme Typical targets raised Localized (acral) <10 major (EMM) atypical targets. Widespread <10 Stevens-johnson Blisters on macules, flat syndrome (SJS) atypical targets. Widespread Overlap SJS-TEN Blisters on macules, flat 10-29 atypical targets. Widespread Toxic epidermal Blisters on macules, flat ≥30 necrolysis (with spots) atypical targets. Widespread TEN without spots No discrete lesions, ≥10 large erythematous areas. Table 1: Showing five type of EM and their clinical features 42 Bajaj P et al. Erythema Multiforme. Table II: Showing clinical features that distinguish SJS, SJS-TEN overlap, and TEN Clinical entity SJS SJS-TEN overlap TEN Primary lesions Dusky red Dusky red lesions, flat Poorly delineated lesions, flat atypical targets erythematous atypical targets plaques, epidermal detachment, dusky red lesions, flat atypical targets Distribution Isolated lesions, Isolated lesions, Isolated lesions, confluence (+) confluence (++) on confluence(+++) on on face and face and trunk. face and trunk and trunk. elsewhere. Mucosal Yes Yes Yes involvement Systemic Usually Always Always symptoms Detachment <10 10 -30 >30 (%body surface area) Erythema Multiforme is a self-limited the lesions. The characteristic “target” or eruption that usually has mild or no “iris” lesion has a regular round shape and prodromal symptoms. All lesions typically three concentric zones: a central dusky or present within approximately 3 days of darker red area, a paler pink or edematous onset. There may be hundreds of lesions, but zone and a peripheral red ring. Some target less than 10% of the body surface area is lesions have only two zones, the dusky or usually involved. The lesions are in a fixed darker red center and a pink or lighter red position with a symmetric distribution. 7 border. 8 They present as circular erythematous Target lesions may not be apparent until plaques in a concentric array with lesion size several days after the onset, when lesions of ranging from 2 to 20 mm. The individual various clinical morphology usually are lesions begin acutely as numerous sharply present, hence the name erythema demarcated red or pink macules that then “multiforme.” become popular. The papules may enlarge Initially the lesions are seen acrally (dorsal gradually into plaques several centimeters in surfaces of hands, feet, elbows, and knees). diameter. The central portion of the papules The face may also be involved. Less or plaques gradually becomes darker red, commonly, lesions may also be seen on the brown, dusky, or purpuric. Crusting or palms, soles, thighs, and buttocks. Lesions blistering sometimes occurs in the center of 43 Bajaj P et al. Erythema Multiforme. may appear at sites of trauma or physical painful (Figure II) . The oral lesions may be irritation and at sites of sun exposure. mistaken for acute necrotizing ulcerative ginigvostomatitis. The mucosal involvement Oral manifestations is more severe in Steven Johnson Syndrome Oral involvement is seen in some 70% of than in erythema multiforme major. patients with EM. Mucosal vesicles or Sometimes extensive hemorrhagic
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