Skip to main content

Main menu

  • Home
  • Articles
    • Current
    • Published Ahead of Print
    • Archive
    • Supplemental Issues
    • Collections - French
    • Collections - English
  • Info for
    • Authors & Reviewers
    • Submit a Manuscript
    • Advertisers
    • Careers & Locums
    • Subscribers
    • Permissions
  • About CFP
    • About CFP
    • About the CFPC
    • Editorial Advisory Board
    • Terms of Use
    • Contact Us
  • Feedback
    • Feedback
    • Rapid Responses
    • Most Read
    • Most Cited
    • Email Alerts
  • Blogs
    • Latest Blogs
    • Blog Guidelines
    • Directives pour les blogues
  • Mainpro+ Credits
    • About Mainpro+
    • Member Login
    • Instructions
  • Other Publications
    • http://www.cfpc.ca/Canadianfamilyphysician/
    • https://www.cfpc.ca/Login/
    • Careers and Locums

User menu

  • My alerts

Search

  • Advanced search
The College of Family Physicians of Canada
  • Other Publications
    • http://www.cfpc.ca/Canadianfamilyphysician/
    • https://www.cfpc.ca/Login/
    • Careers and Locums
  • My alerts
The College of Family Physicians of Canada

Advanced Search

  • Home
  • Articles
    • Current
    • Published Ahead of Print
    • Archive
    • Supplemental Issues
    • Collections - French
    • Collections - English
  • Info for
    • Authors & Reviewers
    • Submit a Manuscript
    • Advertisers
    • Careers & Locums
    • Subscribers
    • Permissions
  • About CFP
    • About CFP
    • About the CFPC
    • Editorial Advisory Board
    • Terms of Use
    • Contact Us
  • Feedback
    • Feedback
    • Rapid Responses
    • Most Read
    • Most Cited
    • Email Alerts
  • Blogs
    • Latest Blogs
    • Blog Guidelines
    • Directives pour les blogues
  • Mainpro+ Credits
    • About Mainpro+
    • Member Login
    • Instructions
  • RSS feeds
  • Follow cfp Template on Twitter
  • LinkedIn
  • Instagram
Research ArticleChild Health Update

Erythema multiforme in children

Ran D. Goldman
Canadian Family Physician July 2022; 68 (7) 507-508; DOI: https://doi.org/10.46747/cfp.6807507
Ran D. Goldman
MD FRCPC
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: rgoldman@cw.bc.ca
  • Article
  • eLetters
  • Info & Metrics
  • PDF
Loading

Abstract

Question Children who present with rashes with “target” lesions are frequently diagnosed with erythema multiforme (EM). This is a self-limiting condition in most children; how should primary care providers differentiate between this and urticaria or Stevens-Johnson syndrome, and what is the recommended course of treatment?

Answer While EM is common in children, urticaria is also very common and tends to be more “waxing and waning” compared with EM’s fixed lesions. Stevens-Johnson syndrome and toxic epidermal necrolysis are more severe and distinct conditions; they have much more substantial mucous membrane involvement and contain widespread erythematous or purpuric macules with blisters. Since EM is a self-limiting condition, treatment of EM in children is generally supportive, and rarely do children need hospital admission for rehydration. In more severe cases involving mucous membranes or substantial pain, some patients will benefit from topical steroids or antihistamines. When children present with signs of herpes infection, antiviral treatment (acyclovir) may be of benefit. Systemic steroids should be reserved for the most challenging cases.

Erythema multiforme (EM) is an immune-mediated, mucocutaneous condition frequently characterized by “target” lesions1 mostly involving the skin but also, at times, involving the mucous membranes (oral, ocular, or genital mucosa). These are annular macules, which later become papules, not infrequently coalescing to plaques.

Early in EM’s course the lesions are isolated, but over a few days they may become confluent and the “target” nature of these lesions may become more difficult to identify. In children, lesions are most frequently located on the extremities with no specific distribution between the arms and legs. Unlike other pediatric conditions with a rash, there is no anticipated progression, and distribution may be just a few new lesions a day or many developing at a rapid pace.

Findings of histologic studies suggest inflammatory perivascular areas and interface infiltration, hyperkeratosis, granulation tissue, mucinosis, and acanthosis.2 The causes of EM are mostly viral (80% to 90%) or drug related.1 Herpes simplex virus type 1 is the most commonly identified cause; other implicated viruses include herpes simplex virus type 2, cytomegalovirus, Epstein-Barr virus (infectious mononucleosis), influenza, and most recently COVID-19 (mostly in patients younger than 30 years or older than 55 years).3 Vulvovaginal candidiasis and mycoplasma pneumonia are also associated with EM.

Medications that may trigger the appearance of EM include antibiotics (eg, erythromycin, nitrofurantoin, penicillins, sulfonamides, tetracyclines), antiepileptic medications, nonsteroidal anti-inflammatory drugs, and vaccines (which are the most common cause in young infants). Other conditions associated with EM are inflammatory bowel disease, hepatitis C, leukemia, lymphoma, and solid-organ cancer malignancy.

When encountering a child with possible EM, inquire about recent infections or symptoms that may represent such infections, as well as history of medications used. In most children the diagnosis can be made after history and examination, and no further testing is recommended.

For children with more severe cases, involving mucous membranes or with substantial pain, empiric therapy may be reasonable. Rarely, and in prolonged or undifferentiated cases, skin biopsy may be needed, but the decision is likely best made after consultation with a dermatologist.

Differential diagnosis

Urticaria is a frequent finding in children, and at times it is hard to differentiate from EM, especially early after presentation. History can help differentiate between these distinct conditions; EM involves fixed lesions for a few days, while urticaria (from allergic reaction or infection) will likely be transient (appear and disappear repeatedly) and will be self-limiting within a few days. However, at times the conditions are indistinguishable, and this has been coined urticaria multiforme.4

The most important differential diagnoses for EM that involve the mucous membranes are Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis. All 3 are immune-mediated epidermal conditions with variable clinical presentations; however, SJS and toxic epidermal necrolysis each have high mortality and lack an effective treatment.5 While in the past these conditions were considered to be on a continuum, they are now recognized as having distinct features and diverse outcomes, resulting in the need for different management strategies. Erythema multiforme is mostly considered to be papular and generally has target-like lesions; SJS usually contains widespread erythematous or purpuric macules with blisters.6

Treatment

For children who present with EM, treatment is generally supportive, with observation. Some will benefit from topical steroids or antihistamines.7 The use of systemic steroids among children has been a source of debate.8 Since EM is a self-limiting condition in most children, systemic steroids should be reserved for the most severe cases—serving as an adjuvant therapy; aiming to suppress cytokine and chemokine response, as well as T cell function; and decreasing adhesion of inflammatory molecules to blood vessel endothelium.9

For children who present with signs of herpes infection, early after its onset primary care physicians should consider antiviral treatment (acyclovir), as it seems to reduce the severity and duration of EM eruptions in some children. One retrospective case series suggested that herpes-associated EM can be precipitated by sun exposure and may not respond to treatment with oral or topical acyclovir.10 Prophylactic treatment with acyclovir can be considered, but evidence is limited.

When oral mucous membranes are involved or when children are systemically unwell, in pain, or experiencing considerable discomfort, admission to hospital for hydration should be considered.

Notes

Child Health Update is produced by the Pediatric Research in Emergency Therapeutics (PRETx) program (http://www.pretx.org) at the BC Children’s Hospital in Vancouver, BC. Dr Ran D. Goldman is Director of the PRETx program. The mission of the PRETx program is to promote child health through evidence-based research in therapeutics in pediatric emergency medicine.

Do you have questions about the effects of drugs, chemicals, radiation, or infections in children? We invite you to submit them to the PRETx program by fax at 604 875-2414; they will be addressed in future Child Health Updates. Published Child Health Updates are available on the Canadian Family Physician website (https://www.cfp.ca).

Footnotes

  • Competing interests

    None declared

  • Copyright © 2022 the College of Family Physicians of Canada

References

  1. 1.↵
    1. Sokumbi O,
    2. Wetter DA.
    Clinical features, diagnosis, and treatment of erythema multiforme: a review for the practicing dermatologist. Int J Dermatol 2012;51(8):889-902.
    OpenUrlCrossRefPubMed
  2. 2.↵
    1. Khan P,
    2. Mudassar M,
    3. Baloch FA,
    4. Waqas M,
    5. Khan A.
    Spectrum of morphological changes in erythema multiforme. J Med Sci 2020;28(3):218-22.
    OpenUrl
  3. 3.↵
    1. Bennardo L,
    2. Nisticò SP,
    3. Dastoli S,
    4. Provenzano E,
    5. Napolitano M,
    6. Silvestri M, et al.
    Erythema multiforme and COVID-19: what do we know? Medicina (Kaunas) 2021;57(8):828.
    OpenUrl
  4. 4.↵
    1. Emer JJ,
    2. Bernardo SG,
    3. Kovalerchik O,
    4. Ahmad M.
    Urticaria multiforme. J Clin Aesthet Dermatol 2013;6(3):34-9.
    OpenUrlPubMed
  5. 5.↵
    1. Cheng L.
    Current pharmacogenetic perspective on Stevens-Johnson syndrome and toxic epidermal necrolysis. Front Pharmacol 2021;12:588063.
    OpenUrlPubMed
  6. 6.↵
    1. Auquier-Dunant A,
    2. Mockenhaupt M,
    3. Naldi L,
    4. Correia O,
    5. Schröder W,
    6. Roujeau JC
    ; SCAR Study Group (Severe cutaneous adverse reactions). Correlations between clinical patterns and causes of erythema multiforme majus, Stevens-Johnson syndrome, and toxic epidermal necrolysis: results of an international prospective study. Arch Dermatol 2002;138(8):1019-24.
    OpenUrlCrossRefPubMed
  7. 7.↵
    1. Riley M,
    2. Jenner R.
    Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Bet 2. Steroids in children with erythema multiforme. Emerg Med J 2008;25(9):594-5.
    OpenUrlFREE Full Text
  8. 8.↵
    1. Chan M,
    2. Goldman RD.
    Erythema multiforme in children: the steroid debate. Can Fam Physician 2013;59:635-6.
    OpenUrlAbstract/FREE Full Text
  9. 9.↵
    1. Michaels B.
    The role of systemic corticosteroid therapy in erythema multiforme major and Stevens-Johnson syndrome: a review of past and current opinions. J Clin Aesthet Dermatol 2009;2(3):51-5.
    OpenUrlPubMed
  10. 10.↵
    1. Weston WL,
    2. Morelli JG.
    Herpes simplex virus–associated erythema multiforme in prepubertal children. Arch Pediatr Adolesc Med 1997;151(10):1014-6.
    OpenUrlCrossRefPubMed
View Abstract
PreviousNext
Back to top

In this issue

Canadian Family Physician: 68 (7)
Canadian Family Physician
Vol. 68, Issue 7
1 Jul 2022
  • Table of Contents
  • About the Cover
  • Index by author
Print
Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article

Thank you for your interest in spreading the word on The College of Family Physicians of Canada.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Erythema multiforme in children
(Your Name) has sent you a message from The College of Family Physicians of Canada
(Your Name) thought you would like to see the The College of Family Physicians of Canada web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Erythema multiforme in children
Ran D. Goldman
Canadian Family Physician Jul 2022, 68 (7) 507-508; DOI: 10.46747/cfp.6807507

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Respond to this article
Share
Erythema multiforme in children
Ran D. Goldman
Canadian Family Physician Jul 2022, 68 (7) 507-508; DOI: 10.46747/cfp.6807507
Twitter logo Facebook logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • Abstract
    • Differential diagnosis
    • Treatment
    • Notes
    • Footnotes
    • References
  • eLetters
  • Info & Metrics
  • PDF

Related Articles

  • No related articles found.
  • PubMed
  • Google Scholar

Cited By...

  • No citing articles found.
  • Google Scholar

More in this TOC Section

  • Accidental cannabis ingestion in young children
  • All-terrain vehicle injuries in children and adolescents
  • Screen time and sleep in children
Show more Child Health Update

Similar Articles

Navigate

  • Home
  • Current Issue
  • Archive
  • Collections - English
  • Collections - Française

For Authors

  • Authors and Reviewers
  • Submit a Manuscript
  • Permissions
  • Terms of Use

General Information

  • About CFP
  • About the CFPC
  • Advertisers
  • Careers & Locums
  • Editorial Advisory Board
  • Subscribers

Journal Services

  • Email Alerts
  • Twitter
  • LinkedIn
  • Instagram
  • RSS Feeds

Copyright © 2025 by The College of Family Physicians of Canada

Powered by HighWire