Essentials of Diseases of the Skin Part 9

Erythema Multiforme.

What is erythema multiforme?

Erythema multiforme is an acute, inflammatory disease, characterized by reddish, more or less variegated macules, papules, and tubercles, occurring as discrete lesions or in patches of various size and shape.

Upon what parts of the body does the eruption appear?

Usually upon the extremities, especially the dorsal aspect, from the knees and elbows down, and about the face and neck; it may, however, be more or less general.

Describe the symptoms of erythema multiforme.

With or without precursory symptoms of malaise, gastric uneasiness or rheumatic pains, the eruption suddenly makes its appearance, a.s.suming an erythematous, papular, tubercular or mixed character; as a rule, one type of lesion predominates. The lesions tend to increase in size and intensity, remain stationary for several days or a week, and then gradually fade; during this time there may have been outbreaks of new lesions. In color they are pink, red, or violaceous. Slight itching may or may not be present. Exceptionally, in general cases, the eruption partakes of the nature of both urticaria and erythema multiforme, and itching may be quite a decided symptom. In some instances there is preceding and accompanying febrile action, usually slight in character; in others there may be some rheumatic swelling of one or more joints.

[Ill.u.s.tration: Fig. 11.

Erythema Multiforme, in which many of the lesions have become bullous--Erythema Bullosum.]

What type of the eruption is most common?

The papular, appearing usually upon the backs of the hands and forearms, and not infrequently, also, upon the face, legs and feet. The papules are usually pea-sized, flattened, and of a dark red or violaceous color.

Describe the various shapes which the erythematous lesions may a.s.sume.

Often the patches are distinctly ring-shaped, with a clear centre--_erythema annulare_; or they are made up of several concentric rings, presenting variegated coloring--_erythema iris_; or a more or less extensive patch may spread with a sharply-defined border, the older part tending to fade--_erythema marginatum_; or several rings may coalesce, with a disappearance of the coalescing parts, and serpentine lines or bands result--_erythema gyratum_.

Does the eruption of erythema multiforme ever a.s.sume a vesicular or bullous character?

Yes. In exceptional instances, the inflammatory process may be sufficiently intense to produce vesiculation, usually at the summits of the papules--_erythema vesiculosum_; and in some instances, blebs may be formed--_erythema bullosum_. A vesicular or bullous lesion may become immediately surrounded by a ring-like vesicle or bleb, and outside of this another form; a patch may be made up of as many as several such rings--_herpes iris_. In the vesicular and bullous cases the lips and the mucous membranes of the mouth and nose also may be the seat of similar lesions.

What is the course of erythema multiforme?

Acute, the symptoms disappearing spontaneously, usually in one to three or four weeks. In some instances the recurrences take place so rapidly that the disease a.s.sumes a chronic aspect; it is possible that such cases are midway cases between this disease and dermat.i.tis herpetiformis.

Mention the etiological factors in erythema multiforme.

The causes are obscure. Digestive disturbance, rheumatic conditions, and the ingestion of certain drugs are at times influential. Intestinal toxins are doubtless important etiological factors in some cases.

Certain foods, such as are apt to undergo rapid putrefactive or fermentative change, especially pork meats, oysters, fish, crabs, lobsters, etc., are, therefore, not infrequently of apparent causative influence. It is most frequently observed in spring and autumn months, and in early adult life. The disease is not uncommon.

What is the pathology of erythema multiforme?

It is a mildly inflammatory disorder, somewhat similar to urticaria, and presumably due to vasomotor disturbance; the amount of exudation, which is variable, determines the character of the lesions.

Name the diagnostic points of erythema multiforme.

The multiformity of the eruption, the size of the papules, often its limitation to certain parts, its course and the entire or comparative absence of itching.

It resembles urticaria at times, but the lesions of this latter disease are evanescent, disappearing and reappearing usually in the most capricious manner, are commonly seated about the trunk, and are exceedingly itchy.

In the vesicular and bullous types the acute character of the outbreak, the often segmental and ring-like shape, their frequent origin from erythematous papules, and the distribution and a.s.sociation with the more common manifestations, are always suggestive.

What prognosis would you give in erythema multiforme?

Always favorable; the eruption usually disappears in ten days to three weeks, although in rare instances new crops may appear from day to day or week to week, and the process last one or two months. One or more recurrences in succeeding years are not uncommon. Those rare cases in which vesicular or bullous lesions are also seen on the lips and in the mouth, are more p.r.o.ne to longer duration and to more frequent recurrences.

What remedies are commonly prescribed in erythema multiforme?

Quinin, and, if constipation is present, saline laxatives. Calcined magnesia is valuable as a laxative. Intestinal antiseptics, such as salol, thymol, and sodium salicylate, are valuable in cases probably due to intestinal toxins. In those exceptional instances in which there may be a.s.sociated febrile action and rheumatic swelling of the joints, the patient should be kept in bed till these symptoms subside. Local applications are rarely required, but in those exceptional cases in which itching or burning is present, cooling lotions of alcohol and water or vinegar and water are to be prescribed. The vesicular and bullous types demand mild protective applications, such as used in eczema and pemphigus.

Erythema Nodosum.

(_Synonym:_ Dermat.i.tis contusiformis.)

What is erythema nodosum?

Erythema nodosum is an inflammatory affection, of an acute type, characterized by the formation of variously-sized, roundish, more or less elevated erythematous nodes.

Is there any special region of predilection for the eruption of erythema nodosum?

Yes. The tibial surfaces, to which the eruption is often limited; not infrequently, however, other parts may be involved, more especially the arms and forearms.

Describe the symptoms of erythema nodosum.

The eruption makes its appearance suddenly, and is usually ushered in with febrile disturbance, gastric uneasiness, malaise, and rheumatic pains and swelling about the joints. The lesions vary in size from a cherry to a hen's egg, are rounded or ovalish, tender and painful, have a glistening and tense look, and are of a bright red, erysipelatous color which merges gradually into the sound skin. At first they are somewhat hard, but later they soften and appear as if about to break down, but this, however, never occurs, absorption invariably taking place. In occasional instances they are hemorrhagic. Exceptionally the lesions of erythema multiforme are also present. Lymphangitis is sometimes observed. In rare instances symptoms pointing to visceral involvement, to cerebral invasion, and to heart complications have been observed.

Are the lesions in erythema nodosum usually numerous?

No. As a rule not more than five to twenty nodes are present.

What is the course of erythema nodosum?

Acute. The disease terminating usually in one to three weeks. As the lesions are disappearing they present the various changes of color observed in an ordinary bruise.