(Erythema exudativum multiforme)
Definition. A common, acute, inflammatory disease of the skin, characterized by various elevated lesions, diverse in size, shape and color.
Symptoms. There is usually a certain amount of constitutional disturbance, such as moderate fever, malaise and scattered pains. Eruptions may be macular, papular, tubercular, vesicular, bullous, or even hemorrhagic, but one or two varieties usually predominate. Although a large or small part of the body may be involved, the favorite locations are the dorsal aspects of the hands and forearms, the face and the extensor surfaces of the feet and legs. Lesions often appear in crops, and increasing in size peripherally or by coalescence, clear in the center. They vary in color, being pink or bright red at the onset, later becoming darker, even showing a bluish or violent tint. Different terms have been applied to the clinical forms of this disease, depending upon the predomination of the individual lesion, such as erythema papulatum when small papules predominate, or erythema tuberculatum when nodules are the main feature. Erythema iris (herpes iris), formerly regarded as a separate disease, simply represents a manifestation of concentric, erythematous rings upon which vesicles or blebs may occur. As many as seven of these distinct circles, one without the other, have been noted. A involution takes place n the center, the patch spreads from the periphery, and hence graduations of color are noted, from a deep, dusky red a to a vivid, bright red, thus giving rise to the name iris. Erythema marginatum is the variety characterized by macular erythema, with sharply defined borders. Erythema perstans, while not proven to be a form of erythema multiforme, is usually considered one of the rare varieties, which may become chronic, persisting without change for months, and assuming circinate or gyrate forms. Subjective symptoms of erythema multiforme are not pronounced, but occasionally range in degree from a simple burning to intense itching, the latter being particularly noticeable when the urticarial element is present.
Etiology and Pathology. Some observers have noted a close family relationship between erytherma multiforme, urticaria, angioneurotic edema and purpura. Some few individuals have shown the recurrent type, having periodic outbreaks at regular intervals, as occurred in one of my own cases, which showed five annual attacks in the month of May. Change of season in the spring and autumn favour outbreaks, as has been seen in recurrence as well as first attacks. The influence of age is pronounced, the majority of cases occurring between the ages of ten and thirty, I have seen only one under one year and only two after the fifteenth year of life. Anemia, chlorosis, rheumatism, gout and other nutritive disturbances, malaria and other endemic diseases, have all been cited as predisposing causes, and it is questionable if the relationship is any closer. Exciting causes may be exposure, local irritants of any sort, internal or external infections, ingestion of such drugs as quinin, chloral, antipyrin, copaiba, arsenic, the iodids and bromids. Certain articles of diet may cause attacks in individuals susceptibly inclined, and I have seen no less than eleven cases occurring in immigrants just landed, where no doubt change of surroundings, lack of exercise and unusual food on shipboard have been the underlying factors. Ossler has contributed much valuable data on the relation of the erythema group and visceral conditions, claiming that the skin lesions are merely surface reflections of visceral disorders. If there is any one factor which seems etiological in the majority of cases, it is ptomaine, either introduced in certain foodstuffs or developed in the digestive tract. This affection is regarded by most observers as an angioneurosis. The poisons, no matter what their nature or origin, act upon the nerve centre and cause the dermal manifestations. A microscopic examination of the skin shows nothing characteristic.
Diagnosis. Urticaria may resemble papular erythema but its lesions last but a few hours, have pronounced stinging or itching sensations, are not localized and usually include some distinct pink and white wheals. Papular eczema presents smaller papules which persist longer and itch more than those of erythema. They do not enlarge and may become vesicular, and the early systemic symptoms of erythema are not present. Measles and rotheln should be readily differentiated but the bullous erythema may simulate pemphigus or dermatitis herpetiformis.
Prognosis and Treatment. Any form is liable to recur. The duration of an ordinary attack is between ten days and five weeks. In severe cases pigmentation may be persistent, and in complicated cases the prognosis must depend upon the nature of the associated disease. Being a self-limited disease, it would seem that the treatment should be largely causal in nature. Hence saline enemas, intestinal antiseptics, laxatives or cultures of the bacillus Bulgaricus in some form may be necessary when intestinal autoinfection is suspected, or if the causes are external and local they need only to be removed. External treatment is employed for its sedative and antipruritic effect. The pathogenetic treatment is all-important, and the following remedies are suggested: Aconite, Agaricus, Apis, Antipy, Belladonna, China sul., Chloral., Cicuta, N. mur., N.phos., Rhus tox., Sal. acid, Sulphur acid, Urt. urens. Vespa.