Multifaceted exudative erythema. Causes and treatment of erythema multiforme exudative. Clinical manifestations of the disease

Exudative erythema or exudative erythema multiforme is a dermatological disease characterized by polymorphic eruptions on the skin and mucous membranes, with a recurrent course.

Exudative erythema can occur against the background of certain infectious diseases or due to the body's sensitivity to certain drugs.

The treatment of exudative erythema is based on the elimination of the factor that provoked its appearance, and the use of methods of symptomatic therapy.

Causes of exudative erythema

There are two forms of exudative erythema: idiopathic (infectious-allergic) and symptomatic (toxic-allergic).

The causes of infectious-allergic erythema have not yet been precisely established. But in the development of this disease, a focal infection plays a certain role (chronic sinusitis, tonsillitis, pulpitis, chronic appendicitis). Patients usually have a high level of sensitivity to bacterial allergens: streptococcus, staphylococcus, E. coli. With relapses of the disease, the factors of the body's natural resistance are suppressed, there is a decrease in T-cell immunity, the number of rosette-forming neutrophils and an increase in the level of B-lymphocytes circulating in the peripheral blood. This suggests that in the infectious-allergic form of the disease, there is a reversible cyclic, T-cell and neutrophilic immunodeficiency. It is caused by a focal infection that contributes to cellular immunodeficiency.

They provoke the development of this condition:

• Viral infection;
• Hypothermia;
• Taking medicines.

Toxic-allergic form of exudative erythema develops as a result of taking certain medications: amidopyrine, sulfonamides, barbiturates, tetracycline. Researchers also do not exclude that autoimmune processes and alimentary factors play a role in the onset of the disease.

Symptoms of exudative erythema

The infectious-allergic form of exudative erythema, as a rule, begins acutely. First appear: malaise, headache, pain in joints, muscles, throat. After 1-2 days, rashes begin to appear on the oral mucosa, skin, red border of the lips, genitals (sometimes). The oral mucosa is affected in 30% of patients. General symptoms disappear 2-5 days after the onset of the rash.

Sharply limited edematous spots or flat pink-red papules appear on the surface of the skin, which rapidly increase in size (up to 2-3 cm). The center of the rash sinks a little, acquiring a bluish tint, blisters filled with serous contents appear. Blisters can also occur on unchanged skin. Itching and burning may occur.

Usually, rashes are localized on the back of the feet and hands, the skin of the soles, palms, extensor surface of the legs, forearms, knee and elbow joints, genital mucosa.

The manifestations of exudative erythema on the oral mucosa are more monotonous, but more severe downstream. Places of localization of rashes - lips, vestibule of the mouth, palate, cheeks. In this case, limited or diffuse edematous erythema appears suddenly. After 1-2 days, bubbles form, opening after 2-3 days with the formation of painful erosions in their place, merging into solid areas. Erosion can be covered with a yellowish-gray coating. On the surface of the erosion, bloody crusts of various thicknesses form on the lips, making it difficult to open the mouth. If the lesion of the mouth is widespread, then due to severe pain, inability to open the mouth, due to the presence of profuse salivation, separated from the areas of erosion, the patient's speech becomes difficult, sometimes it is even impossible to eat.

After 10-15 days, skin rashes begin to resolve. They usually disappear within 15-25 days. Rashes on the oral mucosa are resolved in 4-6 weeks.

Exudative erythema is characterized by a recurrent course (exacerbations usually occur in autumn and spring).

The toxic-allergic form of exudative erythema in appearance resembles the infectious-allergic form. The rash can be fixed or widespread. With fixed rashes with relapses of the disease, the same places are affected as in the previous attack; they can also be joined by rashes in other places. The most common localization of fixed lesions is the oral mucosa. The defeat of the oral cavity is combined with rashes around the anus and on the genitals. Common rashes also affect the oral mucosa.

The symptomatic form of the disease is not characterized by the seasonality of relapses; it is also not combined with the manifestation of general symptoms. The development of the symptomatic form of the disease and the presence of relapses depend on the presence of an etiological factor.

Diagnostics of the exudative erythema

To make a diagnosis, the results of examination of the patient's rashes, dermatoscopy, and anamnesis data are taken into account. The doctor pays special attention to the connection of rashes with the use of certain drugs or an infectious process.

To confirm the diagnosis and exclude other diseases, fingerprints are taken from the affected areas.

Treatment of exudative erythema

In the acute period, the treatment of exudative erythema depends on its symptoms.

If the patient often has relapses of the disease, the rash is extensive, the mucous membranes are affected, there are places of necrosis, then a single injection of diprospan is prescribed.

The main task of the treatment of exudative erythema of the toxic-allergic form is to establish and remove from the body the substance that provoked the development of the disease. For these purposes, the patient is advised to drink plenty of fluids, take diuretics, enterosorbents.

For any form of the disease, patients are shown desensitizing treatment with drugs such as tavegil, suprastin, sodium thiosulfate. The use of antibiotics is justified only with secondary infection of the rash.

As a local therapy for exudative erythema, the following are used:

• Applications of antibacterial agents with proteolytic enzymes;
• Lubrication of the affected skin with ointments based on corticosteroids with antibiotics (dermazoline, trioxazine), antiseptics (solutions of furacilin and chlorhexidine);
• Rinsing the mouth with a decoction of chamomile, lubricating it with sea buckthorn oil.

Exudative erythema is a kind of allergic reaction of the body to bacteriological allergens associated with the presence of foci of infections in the body or to allergens of medicinal origin. Therefore, in order to prevent the primary development or recurrence of this disease, it is necessary to timely identify and eliminate chronic infectious foci or prevent the use of an erythema-provoking drug.

Acute inflammatory process involving dermatological integuments and mucous membranes. It is characterized by the appearance of a significant number of loose polymorphic components.

The disease is distinguished by its reappearance, exacerbation occurs in spring and autumn. The disease occurs at any age, but is most often recorded in children.

In connection with the severity of the patient's condition and the severity of the main manifestations, 2 forms of exudative erythema are distinguished:

Easy, proceeding without manifest pathologies of the general condition of the patient. With this form, there are no lesions of the mucous layers.

Severe, which is characterized by dermatological rashes and mucosal lesions, accompanied by joint disorders from a simple malaise to an extremely difficult general condition.

The rash suggests pinkish spots and red papules. This redness rapidly grows up to 2-3 cm.

Polymorphic and exudative erythema appears in young and middle-aged people, mostly representatives of the stronger sex, however, they are also found in children and in people of advanced age.

In typical cases, the onset of a rash is preceded by a low-grade fever, painful condition, headache, lasting from 3 to 7 days.

Malignant exudative erythema affects people from twenty to forty, while its frequency among the stronger sex is 2 times higher. But isolated cases among children are described.

Where does the disease come from

It is assumed that exudative erythema in 70% of patients is provoked by a decrease in immunity against the background of lingering bacterial infections. Inflammation of the maxillary sinus, inflammation in the ear, inflammation in the palatine or pharyngeal tonsils, nonspecific infectious kidney disease increase the body's susceptibility to pathogens. The disease can also be localized in your mouth.

The other 30% of people develop a toxic-allergic form of the disease. The rash occurs after vaccination, the inclusion of sera, the intake of drugs derived from barbituric acid.

More about the causes of the allergic form

Infectious-allergic form is the most popular variation of the disease. It is characterized by the appearance of blue reddish spots with edema (rounded shape), delimited from the healthy epidermis. Vesicles (vesicles) form in the specks.

Infectious-allergic variation mainly localized on the upper extremities, and may appear together with burning sensation, minor pain syndrome. Consider what the form of erythema looks like in the photo.

The rashes persist for a period of 7 to 14 days, and then disappear, while a brown pigmentation remains. This form occurs in 80% of situations and is usually caused by a herpes infection. In some cases, bacterial or viral infections are the culprit, as well as a reaction to medications.

More about the causes of toxico-allergic erythema

The toxic-allergic form of erythema multiforme and exudative is not characterized by the seasonality of relapses, as a rule, its formation is preceded by common signs. In some cases, these signs occur, mainly in the form of a temperature reaction, rashes may occur with a common type of disease.

For the traditional type of exudative erythema multiforme with damage to the mucous layers, changes are characteristic both in the epithelial and in the connective tissue layer. In some cases, there are large changes in the epithelial cover in the form of necrosis, in others - changes in the connective tissue cover in the form of rapidly formulated edema with the formation of blisters.

Other reasons

Scientists emphasize several causative conditions that have a great influence on the formation of the disease exudative erythema:

• with inflammation of the nasal appendages;
• systemic damage to the periodontal tissue (periodontium);
• with angina;
• the presence of diseases caused by the herpes virus;
• intolerance to certain pharmaceutical substances;
• hypothermia of the body;
• decreased immunity.

Of great importance is the body's hypersensitivity to irritating conditions, stress. Erythema multiforme can cause the formation of an erythema multiforme disease, trauma to the integument, excess ultraviolet radiation, and overheating.

Symptoms at the onset of the disease

Exudative erythema is more often recorded in a child aged 5-7 years and is considered the result of allergic interactions to provoking agents (medicines, household chemicals, food products).

The appearance of polymorphic rashes is traditionally preceded by a sudden complication of general health. Children have fever, joint pain and headaches. The loose components shake at the same time the oral mucosa. All the variety of eruptive components can be analyzed on a photo of erythema in a child.

The clinical signs of the disease in a child and adults are similar. The disease is especially difficult when the mucous membranes of the oral cavity are affected. The child refuses to eat. This further depletes an already exhausted child and reduces the body's defenses. Exudative erythema in young children has a recurrent appearance and can remind of itself from time to time throughout a lifetime, but in some cases the disease suddenly disappears by the age of 17.

The disease is characterized by an acute onset and the onset of flu-like symptoms:

• increased body temperature;
• sore throat and headache;
• joint pain;
• sore throat, coughing;
• general painful condition, impotence;
• loss of appetite;
• muscle pain, body aches;
• swollen lymph nodes.

Further symptoms

The area of ​​erosion can grow, they are prone to fusion with each other, as a result of which the sources are carried to a significant area of ​​the mucosal plane, causing manifested pain, which is even more aggravated when eating and talking. In a child, this leads to a refusal to eat and a rapid dehydration of the body with the formation of a serious condition.

Then, in the scarlet border of the lips, the erosion is covered with brownish fibrinous and sometimes brown bloody crusts, and in the oral cavity - a plaque. Exudative erythema multiforme in the oral cavity is accompanied, in addition to the manifested pain, increased salivation and inflammation of the gums.

After 1–2 days after the onset of the disease, the skin is affected by foci the size of a grain. Infection progresses, the components of the rash reach 2–3 cm in diameter. Papules rise slightly above the surface of the integument, have a scarlet color. Cyanosis appears in the middle.

More about the nature of the rash

Polymorphic erythema is characterized by the appearance of a polymorphic rash (papules, vesicles, bullae, hemorrhages). The rash suggests a distinctly visible pink or scarlet papules, accompanied by swelling. They are prone to rapid growth; in some cases, their diameter reaches up to 3 cm.

As the disease develops, the center of the papules begins to sink, acquiring a blue color. In their area, bubbles appear with exudate from blood or a transparent protein fluid secreted by the serous membranes. Similar formations begin to appear on the healthy plane of the epidermis. The rash is characterized by a burning sensation or intense itching.

After 1-2 days, and in some cases 4-6 days from the onset of the first signs and within 1.5-2 weeks, rashes appear on the skin again, after which the patient's general position improves slightly.

The rash has a type of small (1-2 millimeters) spots of a clearly red color and a rounded shape, slightly rising above the level of the skin due to an edematous roller. They grow rapidly in volume and reach 20 millimeters in diameter.

At the same time, a nodular-papular rash of similar volumes and with precise contours occurs with spots. The rash does not have a tendency to merge with each other and is characterized by a burning sensation.

Spots and papules in the central part after 1-2 days acquire a brown or dull violet-cyanotic tone. Between these 2 areas there is a dull raised rim (a sign of a cockade). Later, a rash with watery contents forms in the center of a papule or speck, and then the walls shrink.

Localization of the rash

A characteristic feature of erythema multiforme is the strict symmetry of the location of the lesions. The elements are localized to a greater extent on the plane of the forearms and the anterior plane of the legs, to a greater extent in the area of ​​the elbow and knee joints, on the anterior plane of the feet and hands, especially along the outer plane.

Less often, a rash occurs on the palms and soles, while in these variants the latter acquire a spilled blue-violet color. At the same time, new rashes appear on the shoulders and in some cases on the face (mainly in the area of ​​the reddish border of the lips), on the neck, on the skin of the sternum, in the area of ​​the perineum and foreskin. Also depicted are individual episodes of single components on the scalp.

Polymorphic erythema is characterized by the appearance of a symmetrical rash over the body and even the oral mucosa. Bullous erythema is localized on the extensor surfaces of the limbs.

In 5% of patients, the rash is localized only on the mucous layers of the oral cavity:

• on the lips and palate;
• the inner plane of the cheeks;
• in the throat.

Basics of treatment

The dermatologist visually examines the clinical picture, focuses on the presence of lingering infections and the adoption of pharmaceutical substances. A survey is carried out to distinguish the disease from urticaria, pemphigus. If there are lesions in the oral cavity, it is necessary to eliminate syphilis. The treatment scheme is drawn up depending on the figure and the severity of the disease.

For any form of the disease erythema multiforme, hypoallergenic nutrition is prescribed, with the exception:

• citrus fruits;
• mushrooms;
• nuts;
• poultry meat;
• smoked foods and any spicy food;
• cocoa;
• coffee and alcohol.

In case of damage to the oral cavity, liquid dishes are used, drinking a huge amount of liquid. If swallowing is not feasible, parenteral nutrition is provided.

With intense relapses, wide lesions of the skin and mucous membranes, treatment of erythema multiforme exudative takes place in stationary conditions. Injections of glucocorticosteroids, in particular Diprospan, are presented. In case of primary infection, hormonal therapy is not prescribed.

In the case of a toxic-allergic form, the toxic element should be detected and removed from the body. Sorbents, diuretics and drinking plenty of fluids are used. Re-infection of the skin is an indication for taking medications.

To eliminate itching, desensitizing substances (Suprastin) are obtained. When the disease passes simultaneously with a viral infection, in this case, the doctor ascribes the taking of drugs to increase immunity, as well as drugs that eliminate the virus.

Multivitamins are needed to maintain immunity. The affected areas are wiped with antiseptics (Furacilin), lubricated with antibacterial ointments (Dermazolin), therapy is not stopped until the rash disappears completely.

Epidemiology

Already Gebra, who singled out this disease as a special nosological unit, indicated that it is seasonal in nature and occurs mainly in October, November, April and May.

Symmetry of the rash is typical

Perhaps, and not uncommon, damage to the mucous membranes. Most often, the mucous membrane of the mouth, especially the cheeks and palate, is affected. Here there are papular efflorescences with lentils or larger, mostly isolated, sometimes merging, slightly protruding above the general level of the mucous membrane, and vesicular elements. The latter, however, in the overwhelming majority of cases are observed already at the stage of erosion, covered with a grayish bloody bloom, surrounded by scraps of the epidermis, the remnants of the former lining of the bladder. Their bottom is sometimes covered with diphtheritic plaque, in rare cases - superficially gangrened, when trying to remove plaque bleeding easily occurs.

The defeat of the mucous membrane of the female genital organs is not uncommon. The clinical picture is similar to the picture of exudative erythema on the oral mucosa, especially the lips. Occasionally, other mucous membranes are also affected - the pharynx, larynx, nasal cavity, urethra.

Disorders of the general condition never reach significant strength. In about half of all cases, there is a fever, mostly of an indeterminate type, mainly with an evening rise in temperature to 37.8-38 °, rarely higher. It can precede the rash for a day or two, then quickly stop. Fever recurs sometimes with repeated outbreaks of the rash. Patients often complain of various subjective disorders - weakness, general malaise, headache, lack of appetite, aches, rheumatoid joint pains.

The rash does not cause particularly unpleasant sensations. Sometimes patients indicate mild itching, moderate tinning in the affected skin, erosion on the mucous membrane can cause severe pain. When localized in the larynx, severe difficulty in breathing is possible.

Etiology and pathogenesis

Exudative erythema multiforme is an infectious disease. Its causative agent has not yet been found, but for its infectious nature it is quite convincingly said:

a clearly expressed increase in the incidence of it in the fall and spring;

the nature of its course.

We do not know anything definite about the pathogenesis of this disease. Recently, in the literature, an opinion has been expressed that the alleged causative agent of the disease enters the bloodstream from some local focus of chronic infection, for example, from a diseased tonsil. As you know, the development of exudative erythema multiforme is often preceded by lacunar angina.

Diagnosis

For the diagnosis of exudative erythema multiforme, the following symptoms are of particular importance:

initial localization on the dorsum of the hands and feet;

symmetry of the location of the rash;

the nature of the evolution of loose efflorescences, especially the rapid retraction of their center, the cyanotic shade of its color with the red color of the peripheral rim, the nature of the eruption in flashes;

plays a well-known role and the season - in the fall and spring, cases of exudative erythema become more frequent.

This disease should not be confused with toxic erythema, which is very similar to it, sometimes developing:

after the use of various medicinal substances, for example, salvarsan, antipyrine, mercury preparations, arsenic, potassium iodide, etc.;

after consuming certain nutrients, such as fish;

with increased processes of putrefaction and fermentation in the intestine;

as a result of some diseases - nephritis, diabetes, uremia;

during pregnancy, such cases have been described more than once.

The fulcrum for correct recognition in most cases is the absence of typical localization, the characteristic evolution of efflorescences of the rash, the spread of the rash by outbreaks, the presence, along with papular and vesicular elements, nodes, pustules, hemorrhages, etc., and, finally, anamnestic data.

Erosions on mucous membranes can be similar to syphilis. The presence of blisters or scraps of epithelium along the edges of the elements, the cyanotic shade of color, the ephemeral flow and nature of the evolution of the elements, the absence of other indisputable syphilides, polyadenitis, etc. protects against an error in the diagnosis. In extreme cases, a Wasserman reaction or a study for a pale spirochete may be required.

The prediction is always favorable, the rash is completely resolved, sometimes leaving temporary peeling and pigmentation of the skin.

Treatment

General treatment consists in the appointment of salicylates in sufficient doses. We always use:

bowel cleansing with laxatives;

immediately thereafter, aspirin in usual doses, for an adult 2.0 per day.

Good results are obtained by the appointment of streptocide - 3-4 tablets per day (0.3 g each).

Topical treatment of skin rashes - for dry rashes, indifferent, cooling mixtures. Shake, moisten the skin and let dry "in the air; repeat 4-5 times a day. For vesicular rashes - indifferent pastes or ointments, for example, zinc paste. In case of lesions of the oral mucosa - emollient warm rinses.

Erythema nodosum

Epidemiology

Erythema nodosum is most often observed in March - May, very rarely from June, and again more often from October. Familial endemics of this disease, and even small epidemics, have been described.

Symptomatology and course

Erythema nodosum occurs mainly in young subjects, especially children. Girls get sick at least 3 times more often than boys. The incubation period for erythema nodosum is not the same in individual cases, it ranges from 3 to 14 days. Almost always, the disease begins with prodromal phenomena: then gradually, then after a tremendous chill, the temperature immediately rises to 39 ° and above, a headache appears, general fatigue, loss of appetite, insomnia - a picture develops that resembles a serious general illness, for example, flu, typhoid fever. Pains in muscles and joints are quite common. In approximately 8% of all cases, the appearance of a rash is preceded by follicular tonsillitis by several days. Gastrointestinal disorders are common in children: nausea, vomiting, constipation or diarrhea. The duration of prodromal phenomena ranges from 2-3 days to a week or more.

Then, as a rule, skin lesions develop sharply. On the extensor surfaces of both legs, bright red nodular infiltrates from a pea to a walnut size appear in varying amounts, slightly rising above the level of normal skin, hemispherical in shape, not sharply limited due to the presence of edema along the periphery. The consistency is dense, palpation causes pain, sometimes spontaneous soreness of the nodes is also noted. Their number is insignificant, sometimes it reaches 20-30 and more. They do not tend to merge or grow. The nodes remain in this form for several days. Then they flatten, become less dense, and in their color a kind of sequential change of shades begins, giving rise to another name for erythema nodosum - dermatitis contusiformis. The bright red color of the nodes at first gives way to bluish-purple, brownish, yellow, greenish. About 2-3 weeks are required for complete, traceless resolution of the nodes, sometimes light pigmentation and slight peeling remain for some time. Ulceration never occurs.

Usually, the rash occurs for some time with repeated outbreaks, so the total duration of the disease is measured for 3-6 weeks, and sometimes more.

Localization

The symmetrical arrangement of erythema nodosum on the extensor surfaces of the skin of both legs is considered typical. In most cases, this is the only localization of the nodes. But they can appear in other places as well. The mucous membranes, apparently, are not affected by erythema nodosum.

General disorders with erythema nodosum are more or less pronounced.

Subjective disorders

The nodes are painful when pressed, and sometimes spontaneous, and it can be very intense. There are never complaints of itching. Relatively frequent indications of rheumatoid pain in the joints; there are also real arthritis.

Objective disorders

The fever reaches its maximum rise in the first days of the rash, then the temperature drops either critically or lytically; with new outbreaks, the rash may rise again. Spleen enlargement is occasionally observed.

From the side of the circulatory system, transient disorders, endo- and myocarditis are not a very rare phenomenon.

In the blood, there was a temporary decrease in erythrocytes and lymphocytes, an increase in monocytes and young forms.

Etiology and pathogenesis

The most probable is the opinion that erythema nodosum is an independent infectious disease caused by an as yet unknown pathogen. Evidence supporting this assumption:

familial endemics described many times;

the course of the disease with prodromal phenomena, fever, disorders of the general condition, etc.;

in the literature, observations have been repeatedly recorded, the analysis of which suggests the idea of ​​the possible contagiousness of erythema nodosum.

The prediction is in the overwhelming majority of cases quite favorable. Returns of erythema nodosum are considered rare, in most cases, persistent immunity remains.

Treatment

At elevated temperatures - bed rest. A good effect not only on subjective sensations (rheumatoid pains, soreness in the nodes), but, apparently, large doses of salicylates, up to 3-4 g per day, also have a good effect on the general course of the disease.

Local treatment is unnecessary in most cases. With severe pain in the nodes, you can apply vodka warming compresses, ichthyol ointment.

Exudative erythema multiforme (erythema exsudativum multiforme) is an acute polymorphic dermatosis, predominantly of an infectious-allergic nature (idiopathic form of erythema), manifested by rashes of a bluish-red color on the skin of the limbs, mucous membranes, sometimes genitals, mainly in spring or autumn, prone to relapse. Toxic-allergic form (symptomatic) exudative erythema is not characterized by the seasonality of relapses.

Information about the etiology and pathogenesis . In the development of the idiopathic form of erythema, the main provoking factors are herpetic, mycoplasma, staphylococcal, streptococcal and other infections. The presence of foci of focal infection in the maxillofacial region is detected in 2/3 of patients. These patients have increased sensitivity to various bacterial allergens, there is a decrease in the parameters of humoral and T-cell immunity factors, neutrophil function, and an increase in B-lymphocytes in the peripheral blood. In the toxic-allergic form of erythema, hypersensitivity to various medicines (sulfonamides, contraceptives, antipyretics, pyrogenic drugs, penicillins, allopurinol, vaccinations against tularemia, cholera) is revealed. Relapses of the disease provoke hypothermia, hyperinsolation and other meteorological factors. In some individuals, it is possible to identify the onset or exacerbation of erythema after eating certain foods (alimentary factors).

Varieties : infectious-allergic (idiopathic), which affects most patients; toxic-allergic (medication).

Favorite localization ... The extensor surfaces of the limbs, often the hands and feet, including the palms and soles, the elbow and knee joints, the face, the vulva, the mucous membrane of the mouth, the red border of the lips, the nasal cavity, the conjunctiva, and the anal canal. The rash can be limited, disseminated, and generalized.

The nature of the rash ... First, areas of limited erythema appear, against the background of which, after a few days, flattened miliary and lenticular papules of a bluish-red color with a depression in the center (elements resemble a target or an iris) are formed. Bubbles and blisters, erosion, bloody crusts form on their surface. When mucous membranes are damaged, erosions with fibrinous plaque occur. The process may involve the trachea, bronchi, eyes, meninges, kidneys.

Subjective sensations ... Itching, less often burning and soreness in places of skin rashes. Lesions of the oral mucosa are always accompanied by severe pain.

General phenomena . Fever, joint and muscle pain, weakness, malaise.

Data supporting the diagnosis ... Acute onset, signs of intoxication, polymorphism and symmetry of cyanotic-red (dark pink) rashes. Relapse usually lasts 3-4 weeks. The seasonality of relapses is observed in the infectious-allergic form of the disease. With a mild course of dermatosis with the presence of vesicles and blisters, Nikolsky's symptom is negative.

Clinical forms

According to the severity of manifestations, they are distinguished:

Simple or mild form (papular, usually occurs without damage to the mucous membranes).

Vesicular-bullous form (moderately severe).

Bullous (severe), including Stevens-Johnson syndrome.

An extremely severe form of the disease (Lyell's syndrome). At the initial stage of the development of Lyell's syndrome, typical target-like skin rashes, characteristic of erythema multiforme, are detected in half of the patients. Then, widespread erythema and epidermal necrolysis phenomena quickly appear.

Clinical picture

Simple form . Numerous typical papules with a diameter of 1-2 cm are determined on the skin, with a depression in the center, which regress within 1-2 weeks. A gallbladder reaction on the oral mucosa is possible with the formation of bloody, dirty crusts, the appearance of edema, cracks on the lips, and soreness.

Vesicular-bullous form ... A few erythematous plaques, with a blister in the center and a ring of vesicles along the periphery. Often the mucous membrane of the mouth and lips is involved in the process.

Relapses of the above forms of erythema multiforme are associated with the reactivation of the herpes virus, since the use of acyclovir in a number of patients leads to the relief of exacerbations of dermatosis.

Bullous form (Stevens-Johnson syndrome) is a severe type of exudative erythema multiforme or a toxic-allergic reaction to medication. On the oral mucosa, there are extensive blisters and bleeding erosion, massive hemorrhagic crusts. The symptoms of cheilitis and stomatitis make it difficult to eat due to severe pain. It is possible to develop catarrhal or purulent conjunctivitis, corneal ulceration, uveitis, panophthalmitis, lesions of the mucous membranes of the genitals with involvement of the bladder and impaired urination. On the skin, multiple maculopapular rashes are found, blisters with a positive Nikolsky symptom, less often pustules, sometimes paronychia occurs. Prolonged fever is characteristic, possibly the development of pneumonia, nephritis, diarrhea, polyarthritis, otitis media. Without treatment, the mortality rate is 5-15%. These manifestations must be differentiated from Lyell's syndrome. It is believed that the presence of a gallbladder reaction on more than 30% of the surface of the skin corresponds to the clinic of Lyell's syndrome.

Extremely severe form (Lyell's syndrome). Most of the cases of Lyell's syndrome are associated with the intake of drugs by patients, at least with the use of certain chemical compounds, as well as viral and mycoplasma infections, vaccinations. In some cases (5% of patients), the syndrome develops without prior prescription of medication.

Toxic-allergic reaction begins with lesions of the face and extremities in the form of erythema, maculopapular rash, or typical rash of erythema multiforme. Within a few hours - days, the eruptive elements merge and occupy the entire skin. Further, thin-walled flaccid bubbles form, which quickly merge and look like whitish areas resembling tissue paper. Nikolsky's symptom is sharply positive. When traumatizing the affected areas, the necrotic epidermis easily exfoliates, exposing the red, eroded, painful surface of the papillary layer of the dermis, which corresponds clinically to a second degree burn. In most patients, the erosive process affects the mucous membrane of the cheeks, lips, conjunctiva, skin and mucous membranes of the genital organs, the perianal region. Epithelialization of erosions begins with the period of blistering and continues throughout the entire period of the disease, which lasts about 3-4 weeks. In the recovery stage, there is abundant large-lamellar peeling and sloughing of the unreleased necrotic epidermis in large layers. During the development of the main clinical manifestations of Lyell's syndrome, high fever and flu-like syndrome are characteristic. Often, renal failure, ulcerative necrotic changes in the trachea, bronchi, gastrointestinal tract, various pathologies on the part of the organ of vision, up to blindness, develop. Detection of neutropenia in a peripheral blood test is a poor prognostic symptom. Mortality in Lyell's syndrome reaches 30% and depends on the area of ​​the affected skin and the age of the patients (elderly people die more often). Possible causes of death: sepsis, gastrointestinal bleeding, severe violations of the water-electrolyte balance.

In addition to the above-mentioned severe forms of toxic-allergic reactions, in the practice of a dermatologist, skin reactions to medication with a milder clinical course are often observed: a common and fixed form of erythema multiforme exudative.

At fixed form the mucous membrane of the mouth, genitals, perianal region is affected. Relapses usually occur at the site of a former rash. The inflammatory response in the area of ​​the blisters may be absent. Seasonality of relapses is not typical.

For common form common phenomena (usually a temperature reaction) and the occurrence of lesions in other areas of the skin are characteristic. In order to prevent recurrence of the disease, it is necessary to identify the allergen and subsequently develop recommendations for eliminating the patient's contact with this provoking factor.

Histopathology. Vacuolar degeneration in the lower layers of the epidermis, epidermal cell necrosis, suprabasal and subepidermal blisters without acantholysis. Lymphohistiocytic infiltration around the vessels and in the area of ​​the basement membrane, extravasation of erythrocytes.

Differential diagnosis . Pemphigus vulgaris(absence of erythema, papules, positive symptom of Nikolsky, the presence of acantholytic cells in smears-prints from erosions).

Dermatosis Duhring (herpetiformity of the arrangement of elements, sensitivity to iodine, the effect of using DDS in patients).

Chronic erythema migrans Afzelius-Lipschutz (skin manifestations Lyme borreliosis). A cyanotic-red spot with a hemorrhagic crust in the center appears at the site of the tick's suction, which grows into a ring over an area the size of a child's palm and more (stage 1). A few weeks later, as a result of dissemination of the spirochetes, cardiac and neurological symptoms appear (stage 2). A year or more after the tick bite (stage 3), complications develop: skin lesions in the form of chronic atrophic acrodermatitis, severe changes in the joints, heart, central nervous system, peripheral nervous system.

When establishing a diagnosis, it is also necessary to exclude medicinal toxidermias, infectious exanthema (scarlet fever, measles, rubella), dermatomyositis, thermal burns, phototoxic reactions, scalded skin syndrome.

Exudative erythema (multiforme) is one of the clinical manifestations of erythema, which is characterized by the formation of a polymorphic rash on the mucous membranes and skin. The disease tends to relapse (especially in the spring and autumn) and is most common among middle-aged and young people.

The term "exudative erythema" is used to refer to a similar clinical rash that develops with certain infectious diseases or due to allergy to drugs. Thus, there are two main forms of exudative erythema:

• Idiopathic (infectious-allergic);
• Symptomatic (toxic-allergic).

Symptoms of exudative erythema

With idiopathic exudative erythema, the disease begins with prodromal phenomena (malaise, weakness, low-grade fever, sore throat, muscles, joints), developing against the background of angina, acute respiratory disease, hypothermia. The symptomatic form of the disease manifests itself mainly after taking certain medications (antibiotics, barbiturates, sulfa drugs, amidopyrine), administration of vaccines and serums. In the future, the clinical picture of the disease of both forms does not differ.

Exudative erythema is characterized by a symmetrical lesion of the skin of the extensor surfaces (forearms, hands), face, neck, back of the feet, legs. Often, the oral mucosa is involved in the inflammatory process. The rash has the appearance of spots with a diameter of 3-15 mm, rounded with sharp borders of bright red color, differing in the retraction of the central part, as a result of which a "ring within a ring" appears. Spots tend to merge with the formation of figures with polycyclic outlines (arcs, garlands, etc.). With exudative erythema, new rashes appear during the first days of the disease and are accompanied by headache, malaise, and fever. The duration of the inflammatory process, as a rule, is 10-15 days and ends with the patient's recovery.

Treatment of exudative erythema

In milder forms, the treatment of exudative erythema is mainly symptomatic, in which therapy is aimed at eliminating the main signs of the disease. At the same time, special ointments containing adrenal cortex hormones are applied to the area of ​​lesions. The mucous membrane of the mouth is cleaned with cotton swabs moistened with antiseptic solutions. In order to reduce painful sensations, lidocaine can be used.

In more severe cases, exudative erythema is treated with corticosteroid hormones (prednisone 40-60 mg / day). At the indicated dose, the drug is taken for 5-7 days, then every 2-3 days the dose is reduced by 5 mg until it is completely canceled. In the presence of a secondary infection, antibiotic therapy is used. When joining the disease of herpes infection, antiviral drugs are prescribed (remantadine, acyclovir, 200 mg 3 times a day).

With necrotic plaque on the surface of erosions that have appeared, applications of proteolytic enzymes (chymotrypsin, lysoamidases) are used, after which keratoplastic agents (sea buckthorn and rosehip oils, carotolin, solcoseryl, oil solutions of vitamins A, E) are used to accelerate tissue epithelization.

One of the most severe forms of exudative erythema is called Stevens-Johnson syndrome: it is characterized by high fever, severe pain in muscles and joints, bullous lesions of the mucous membranes of the nose, mouth, genitals. Often, the mucous membranes of the respiratory tract, esophagus, and stomach are involved in the pathological process.

When blisters appear on the skin surface, it is recommended to open them with sterile scissors. The prognosis for timely treatment of exudative erythema (except for Stevens-Johnson syndrome) is almost always favorable.

Prevention of exudative erythema

Prophylactic treatment of exudative erythema is carried out in the spring and autumn (several months before the expected relapse). To this end, measures are being taken to sanitize foci of chronic infection, prevent chills, as well as general hardening of the body. Prophylactic drug treatment consists of taking:

• Levamisole (150 mg for 2 consecutive days, with an interval of 5 days);
• Ethacridine lactate (within 10-15 days, 0.05 g 3 times / day).

With the toxic-allergic form of exudative erythema, it is important not to allow the intake of the medication that provokes this disease.

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