Reactive Erythema and Bullous Reaction

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These are immunologic reactions characterized by reddening with or without blistering of the skin and/or mucosa. The common types are erythema multiforme, Stevens-Johnson syndrome and toxic epidermal necrolysis (TEN). With all these conditions, there could be accompanying extensive denudation of skin with consequent fluid and electrolyte loss and a risk of secondary bacterial infection. All three conditions should be considered as emergencies requiring intensive care.

Erythema multiforme presents as itchy, target-like, non-scaly lesions of the palms, soles, forearms and legs.

Stevens-Johnson syndrome is characterized by erythema and blister formation, which additionally involves the mucous membranes (conjunctiva, mouth, genitals etc.). 

Toxic epidermal necrolysis (TEN) is a generalized scalded type of skin  reaction, often due to an allergic reaction to drugs. A similar reaction occurs in children termed staphylococcal scalded skin syndrome, which is caused by Staphylococcus aureus.

Cause

  • Viral infections e.g. herpes simplex virus, retrovirus, cytomegalovirus
  • Mycoplasma pnuemoniae infection
  • Adverse drug reaction e.g. to sulphonamides, penicillin, NSAIDS, anticonvulsants etc.
  • Malignancy

Symptoms

  • Fever
  • Blisters
  • Itchy rash
  • Sore throat
  • General malaise
  • Discharging painful eyes
  • Asymptomatic 

Signs

  • Fever
  • Flaccid bullae 
  • Genital and/or oral ulcerations
  • Denuded area of skin

Investigations

  • FBC
  • BUE & creatinine
  • HIV screen 
  • Blood and wound cultures (if indicated) 

TreatmentTreatment Objectives

  • To maintain adequate hydration
  • To maintain adequate nutrition
  • To correct electrolyte imbalance
  • To maintain normal body temperature
  • To prevent secondary infection
  • To identify and eliminate underlying cause 
  • To prevent further exposure to the causative agent or drug

Non-pharmacological treatment

  • Withdrawal of identifiable causative agent or drug
  • Maintenance of adequate input and output of fluid
  • Adequate oral fluids 
  • Prevent contact of ulcerated skin with contaminated linen using a nursing cradle
  • Early ophthalmological consultation
  • Nutritious diet

Pharmacological treatment 

 

 

 

 

 

  •  

Referral CriteriaRefer all patients to appropriate specialist. 

For adequate rehydration

  • Normal saline, IV, 

For Pain and Fever

Evidence Rating: [A]

  • Paracetamol, oral,

Adults

500 mg-1 g 6-8 hourly 

Children

6-12 years; 250-500 mg 6-8 hourly

1-5 years; 120-250 mg 6-8 hourly

3 months-1 year; 60-120 mg 6-8 hourly

For Control of the Immune Process in patients who can swallow

Evidence Rating: [C]

  • Prednisolone, oral, (at onset of condition)

Adults 

0.5-1 mg/kg daily and taper off over 7-10 days

Children

0.5 mg/kg daily and taper off over 7-10 days

For Control of the Immune Process in patients who cannot swallow

  • Hydrocortisone, IV,  

Adults

100 mg 6 hourly until able to swallow 

Then 

  • Prednisolone, oral, as above 

Children

4 mg/kg 6 hourly until able to swallow 

Then 

  • Prednisolone, oral, as above 

To treat Secondary Bacterial Skin Infection or Mycoplasma Pneumonia 

Evidence Rating: [B]

  • Azithromycin, oral,

Adults

500 mg daily for 5 days

Children

10 mg/kg once daily for 5 days

< 6 months; not recommended

Or

  • Erythromycin, oral,

Adults

500 mg 6 hourly for 7 days 

Children

6-12 years; 250 mg 6 hourly for 7 days

1-5 years; 125 mg 6 hourly for 7 days

< 1 year; 62.5 mg 6 hourly for 7 days

For prevention of skin infections

Evidence Rating: [C]

  • Chlorhexidine solution 4%, topical, 

Or 

  • Cetrimide 15%, topical,

Or

  • Povidone iodine solution 10%, topical

Note: Do not use silver sulfadiazine as it is a sulfa drug for skin care

For oral ulcers

  • Povidone iodine 1% mouthwash, 12 hourly 

Or

  • Chlorhexidine 0.12% mouthwash, 12 hourly