Eritema multiforme en niños.

Published in Dermatology

Journal Scan / Review · August 11, 2019

Triggers, Clinical Manifestations, and Management of Pediatric Erythema Multiforme

Journal of the American Academy of Dermatology

TAKE-HOME MESSAGE

• This systematic review of 113 studies, which included 580 cases of erythema multiforme (EM) in children, revealed that triggers were most often infectious (48.1%), drug-related (24.1%), idiopathic (13.8%), or other causes including vaccinations (3.9%). These triggers were similar to those observed in adults. Herpes simplex virus and Mycoplasma pneumoniae contributed the most to infectious causes. Subanalysis of EM in infants found a higher rate of cases triggered by vaccinations (47.3%). When medical treatment was used, systemic corticosteroids, antivirals, and antibiotics were most common therapies. Few cases had long-term sequelae (1.3%).

• Supportive care, with corticosteroids in severe cases, is the mainstay of treatment.

– Margaret Hammond, MD

Written by

 

 

Jacob O Levitt MD

Zoghaib et al performed an exhaustive review of the literature, effectively summarizing pediatric erythema multiforme (EM). In their limitations, they note the possible confusion between erythema multiforme major and Stevens-Johnson syndrome. Other than identifying an etiology, I would argue that work-up and management of either condition is largely the same. In the former, one might be inclined to rule out HSV-1 and -2 or mycoplasma serologically. In both, one would take a medication history. One might broaden the differential to include Kawasaki disease, Behçet's disease, and paraneoplastic pemphigus.

Treatment of EM does not vary much from pediatric to adult patients. No one thing works all of the time. In my hands, either prednisone or cyclosporine is most reliable; however, famciclovir, apremilast, and etanercept are relatively safe alternatives. Thalidomide might be reserved for refractory cases.

BACKGROUND

Erythema multiforme (EM) is an acute inflammatory mucocutaneous condition. EM is rarely described in children and infants.

OBJECTIVE

To investigate the triggers, clinical manifestations, and treatment of pediatric EM.

METHODS

Systematic literature review of pediatric EM.

RESULTS

After full-text article review, we included 113 articles, representing 580 patients. The mean age was 5.6 years, ranging 0.1-17 years. Infectious agents were the main triggers: herpes simplex virus (HSV) in 104 patients (17.9%) and Mycoplasma pneumoniae in 91 patients (15.7%). In total, 140 cases (24.1%) were drug-related and 89 cases (15.3%) had other triggers, such as vaccines (19 patients, 3.2%). In total, 229 patients had EM major (39.5%). Treatment was supportive care only (180 patients, 31.1%), systemic corticosteroids (115 patients, 19.8%), antivirals (85 patients, 14.6%), and antibiotics (66 patients, 11.3%), mostly macrolides (45 patients, 7.7%). Long-term sequelae were rare (1.3%). Pediatric EM was reported in 19 infants (3.2%). The main trigger was vaccination (9 patients). Infantile EM was EM major in 2 cases and EM minor in 17. Infants were less prone to develop EM major than older children (P < .01). Pediatric EM was recurrent in 83 cases (14.3%), which was triggered by HSV in 36 patients (61%). Recurrence affected older children.

LIMITATIONS

Potential confusion between Steven Johnson syndrome and EM major in addition to publication bias.

CONCLUSION

Pediatric EM is a rare disease, mainly triggered by infections. This condition can affect all mucosal surfaces, most commonly the oral mucosae. The diagnosis is clinical, and management relies on supportive care. Vaccines are a particular trigger in infants. Recurrent cases are most commonly linked to HSV. Dermatologists and pediatricians should be aware of this potentially recurrent and severe condition.

• Article Citation

Journal of the American Academy of Dermatology

Triggers, Clinical Manifestations, and Management of Pediatric Erythema Multiforme: A Systematic Review

J Am Acad Dermatol 2019 Jul 19;[EPub Ahead of Print], S Zoghaib, E Kechichian, K Souaid, B Soutou, J Helou, R Tomb 

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Benjamin Hidalgo-Matlock
Skin Care Physicians of Costa Rica

Clinica Victoria en San Pedro: 4000-1054
Momentum Escazu: 2101-9574

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