Symptoms of erythema multiforme. Erythema multiforme exudative - photo of characteristic symptoms

What is exudative erythema?

Exudative erythema multiforme is one of the clinical forms of erythema, characterized by an acute course, the formation of a polymorphic rash on the skin and mucous membranes, and a tendency to relapse (especially in autumn and spring). Also, this term is used to refer to rashes that are similar in clinical manifestations, developing due to an allergy to any drug or with certain infectious diseases. Thus, two forms of exudative erythema are distinguished: infectious-allergic and toxic-allergic.

The disease is more common among young and middle-aged people.

Causes of exudative erythema

The causes of exudative erythema are not well understood. Most often, patients simultaneously with infectious-allergic exudative erythema are diagnosed with focal infections, which include sinusitis, tonsillitis, pulpitis, chronic appendicitis. Often a factor in the development of the disease becomes an increased sensitivity to bacteria, streptococcus, E. coli, and so on.

Toxic-allergic exudative erythema occurs mainly from individual intolerance to certain medications. These include barbiturates, amidoprine, sulfanilamide, tetracycline, and so on. They influence the development of the disease and autoimmune processes in the human body.

Symptoms of exudative erythema

Exudative erythema multiforme usually has an acute onset. Its first symptoms are fever, excruciating headache, general symptoms of malaise (weakness, loss of appetite, muscle and joint pain), and a sore throat may occur with. The rash usually appears on the second day. They are localized on the mucous membranes, skin and lips.

The rash is pinkish spots and reddish papules that grow rapidly up to two to three centimeters. They tend to merge. Usually, serous blisters appear in the center of the papule, which burst and form erosions. The rashes are painful, the patient feels a burning sensation or.

The rash is localized mainly on the skin of the feet and palms, on the folds of the limbs, forearms, knees, genitals, elbows and knees.

Appearing on the mucous membranes, the rash gives a person much more inconvenience, because, opening up, the blisters form very painful wounds that tend to merge. Such erosive areas can cover the entire oral mucosa and lips of a person. Sometimes the wounds are covered with a grayish-yellow coating, attempts to remove which cause parenchymal bleeding. At the same time, the patient suffers from severe salivation, pain, speech becomes difficult for him, and eating becomes impossible.

The rash on the skin usually lasts 10-15 days, after which it goes away on its own. The mucosal lesion has a less favorable course and disappears only in the fourth or sixth week.

The infectious-allergic form of exudative erythema is prone to seasonal relapses. The disease affects people mainly in spring and autumn.

The toxic-allergic form of the disease is not characterized by previous general symptoms or relapses. The manifestation of the disease depends only on the person's contact with the allergen.

Treatment of exudative erythema

Exudative erythema multiforme is always an allergic reaction, therefore, in order to avoid recurrence of the disease, it is necessary to eliminate all contact with allergens. For food allergies, enterosorbents are prescribed. If erythema occurs along with any secondary infection, the patient is prescribed antibiotics. In the treatment of exudative erythema, corticosteroids (in severe cases), vitamins (B, C), and potassium preparations are also used. Antifungal drugs, painkillers (ointments, aerosols, solutions) and antiseptics are also used.

The prognosis of treatment is favorable. Complications and deaths are possible only with the appearance of Stevens-Johnson syndrome. This is a severe variant of the course of exudative erythema, accompanied by prolonged fever, merging of erosions on the mucous membranes with the formation of a single erosive bleeding area. The disease can affect the eyes, causing keratitis and conjunctivitis. Complications of this process are myocarditis and meningoencephalitis, as a result of which a fatal outcome may occur. Another option for a severe course

Erythema multiforme exudative (MEE) is an acutely developing disease characterized by polymorphic rashes on the skin and mucous membranes, a cyclic course and a tendency to relapse, mainly in autumn and spring.

Etiology of erythema multiforme exudative

To date, the etiology of this disease has not been fully elucidated. However, the main forms of exudative erythema are infectious-allergic and toxic-allergic.

In the infectious-allergic form in patients with the help of skin tests, an allergic reaction to bacterial allergens is often determined - staphylococcal, streptococcal, E. coli.

The state of infectious allergy, observed in a number of patients with erythema multiforme exudative, is indirectly confirmed by a complex of serological reactions - the determination of antistreptolysin O, C-reactive protein, etc. The most pronounced allergic reactions are recorded in patients with severe acute infectious diseases, with frequent relapses.

According to the latest data, in 1/3 of cases, a viral etiology of the disease is assumed, when Coxsackie ordinary herpes viruses can act as initial factors. There have been reports of the occurrence of the disease in individuals suffering from recurrent herpetic infection according to the type of immune reaction of the third type, which is called postherpetic exudative erythema multiforme.

The third type of allergy is the immunocomplex mechanism of immunopathological reactions: the production of IgG, IgM precipitating antibodies, antigen excess, pathogenic reactions initiated by immune complexes (IC) through complement and leukocyte activation. Allergic reactions of the third type (immunocomplex) on the oral mucosa are associated with the formation of immune complexes. They can be caused by either bacterial or drug antigens. These reactions lead to necrosis resulting from damage to the vascular wall by immune complexes that are formed inside the vessels and deposited on the basement membrane.

The seasonal nature of the disease, the short duration of the disease attacks, spontaneous regression of the disease, the absence of an anamnesis characteristic of an allergic disease indicates that not only allergic mechanisms are the basis of erythema multiforme, and it cannot be classified as a purely allergic disease.

As with other infectious-allergic diseases, in the anamnesis of patients, past and concomitant diseases of various organs and systems are determined (especially often - chronic infectious foci in the nasopharynx).

The etiological factors of the toxic-allergic form of exudative erythema multiforme are most often drugs, primarily sulfonamides, antipyrine, amidopyrine, barbiturates, tetracycline, anesthetics.

A severe form of exudative erythema is Stevens-Johnson syndrome. Most often, Stevens-Johnson syndrome is associated with the use and intolerance of sulfa drugs, salicylic acid derivatives, pyrazolone, and antibiotics.

Clinic of multiform exudative erythema

Infectious-allergic form of exudative erythema usually begins acutely, often after hypothermia. Body temperature rises to 38-39 ° C, headache, malaise, often sore throat, muscles, joints.

After 1-2 days, against this background, rashes appear on the skin, oral mucosa, red border of the lips and occasionally on the genitals. Rashes can be noted only in the mouth.

Oral mucosa in erythema multiforme exudative it is affected in almost 1/3 of patients, an isolated lesion of the oral mucosa is observed in approximately 5% of patients.

2-5 days after the appearance of the rash, the general phenomena gradually disappear, however, in a number of patients, the temperature reaction and malaise can last for 2-3 weeks.

On the skin, the disease is manifested by the appearance polymorphic rashes. Initially, they are usually localized on the back surface of the hands and feet, on the skin of the forearm, shins, less often on the face, neck, torso, sometimes covering these areas completely. Red, bluish-red, clearly defined spots appear. Their sizes vary from the size of a cherry stone to a penny coin. Most of them are round in shape. Their central part is edematous, raised. It quickly turns into a bubble. Usually, along with the spots, rounded, edematous papules also appear, often stagnant red, occasionally pale pink. Blisters with serous and sometimes hemorrhagic contents may appear on the surface of the papules. The central part of the papule often gradually sinks and becomes cyanotic or cyanotic-violet. Along the periphery, the papules gradually grow, and as a result, a bright red corolla is formed. As a result of this evolution of papules, the formed element takes the form of concentric figures, the color of which gradually changes from bluish-violet in the center to bright red (acute inflammatory) at the edges. When the contents and covers of the bubbles that appear in the center of the elements dry, dark crusts appear.

The severity of the course of erythema multiforme exudative is mainly due to damage to the oral mucosa. The process in the mouth is more often localized on the lips, the bottom of the oral cavity, the vestibule of the oral cavity, on the cheeks and palate.

Erythema multiforme exudative in the mouthat begins with the sudden appearance of diffuse or limited edematous erythema, especially on the lips. After 1-2 days, vesicles form against this background, which exist for 2-3 days, then they open up and very painful erosions appear in their place, which can merge into continuous erosive foci, sometimes capturing a significant part of the mucous membrane of the oral cavity and lips. Erosions are covered with fibrinous plaque. When plaque is removed from the surface of the affected area, a bleeding surface is exposed. On the edge of some erosions in the first days after the opening of the blisters, one can see grayish-white fragments of the epithelium, which are the remnants of the blisters. Nikolsky's symptom is negative.

In some patients erythema multiforme exudative attack accompanied only by the only very limited painless erythematous or erythematous-bullous rashes. On the surface of the erosions located on the red border of the lips, bloody crusts form, which make it difficult to open the mouth. When a secondary infection is attached, the crusts acquire a dirty gray color. On the mucous membrane of the mouth with this form, blisters often appear against an outwardly unchanged background, erosion in place of which heals very slowly. Sometimes inflammatory phenomena join later, after the opening of the blisters. The defeat of the oral cavity with a fixed form is most often combined with rashes on the genitals and around the anus.

Toxic-allergic form of exudative erythema multiforme seasonality of relapses is not characteristic, usually its development is preceded by general symptoms. Sometimes these symptoms, mainly in the form of a temperature reaction, can accompany the appearance of rashes in a common variety of the disease.

The occurrence of a toxic-allergic form of exudative erythema multiforme, the frequency of its recurrence depends on the contact of the patient with the etiological factor. The nature of the etiological factor and the state of the body's immune system determine the duration of the course of relapses and the severity of the lesion in each of them.

For the classic type of erythema multiforme exudative with lesions of the mucous membranes, changes are characteristic both in the epithelial and in the connective tissue layer. In some cases, there are predominant changes in the epithelial layer in the form of necrosis, in others - changes in the connective tissue layer in the form of pronounced edema with the formation of blisters.

In the mucous membrane, perivascular infiltrates are formed from mononuclear cells with an admixture of neutrophilic and eosinophilic granulocytes. There may be swelling of the papillary layer. In the cells of the spinous layer - dystrophy, in some places necrotic changes in epidermocytes. In some cases, the cells of the infiltrate penetrate the epithelial layer and may form intraepidermal blisters. In the papillary layer - mild infiltration around the superficial vessels, areas of the epithelium with necrosis. Affected cells due to the lysis of their nuclei merge into a continuous homogeneous mass.

The cytological picture of smears-imprints or scrapings from the bottom of erosions corresponds to an acute nonspecific inflammatory process. In large numbers, there are single unchanged segmented neutrophils or in places of their accumulation (with a long period of the disease, a significant part of them is destroyed, some retain their normal appearance) and lymphocytes.

In the vast majority of patients, scrapings show a large number of polyblasts of various sizes and macrophages (30-60%) in the cytogram, many eosinophils. Layers and single epithelial cells of the superficial and intermediate layers without features.

With a widespread lesion of the oral cavity due to severe pain, abundant discharge from the surface of erosion, salivation, speech is difficult, even liquid food cannot be taken, which sharply exhausts and weakens the patient. Poor hygienic condition of the oral cavity, the presence of carious teeth, inflammation of the gingival margin aggravate the process. On the mucous membrane of the oral cavity, the resolution of rashes occurs within 3-6 weeks.

For erythema multiforme exudative characteristically relapsing course. Relapses usually occur in spring and autumn. In rare cases, the disease takes a persistent course, when the rash recurs almost continuously for several months and even years.

In toxic-allergic form of MEE rashes can be widespread.

The mucous membrane of the oral cavity is the most common localization of rashes in a fixed variety of the toxic-allergic form of exudative erythema multiforme, which is usually caused by hypersensitivity to medications.

With relapses of the disease, rashes necessarily occur in places where they have already appeared in previous relapses of the disease; at the same time, rashes can be observed in other areas.

Stevens-Johnson syndrome (acute mucocutaneous ocular syndrome). Named after the American pediatricians who first described it in 2 children.

According to most modern authors, this syndrome, as well as Lyell's syndrome similar to it, fit into the clinical picture. severe form of exudative erythema multiforme and serve as a manifestation of the hyperergic reaction of the body in response to the introduction of any foreign agent.

The disease begins with a very high temperature (39-40°C), which slowly decreases and remains subfebrile for 3-4 weeks. Intoxication of the body is pronounced. Rashes appear simultaneously on most mucous membranes and on the skin. The mucous membrane of the mouth, lips, tongue are edematous, there are flaccid blisters, vesicles, erosions, ulcers. A very large surface of the oral mucosa is affected, making it almost impossible to eat, even liquid. The lips are covered with bloody-purulent crusts. The conjunctiva of the eyes is also usually affected (bubbles, erosions), the skin of the eyelids is sharply edematous, covered with blisters and crusts. Keratitis and panophthalmitis in severe cases end in blindness. The mucous membranes of the genitals swell sharply, polymorphic lesions appear. Frequent nosebleeds. When the larynx and trachea are involved in the process, a tracheotomy is sometimes necessary. Violations of the function of the gastrointestinal tract are pronounced, sometimes there are concomitant diseases: hepatitis, bronchitis, pleurisy, pneumonia, etc. body surface. Nikolsky's symptom is often positive. Deaths have been described as a result of damage to the central nervous system and the development of coma.

In severe form of exudative erythema multiforme, open erosive surfaces are secondarily infected with numerous microflora of the oral cavity, especially if the oral cavity has not been previously sanitized. There is plaque on the teeth and tongue, bad breath. The addition of fusospirachetous microflora can complicate exudative erythema multiforme with Vincent's stomatitis. Regional lymph nodes are painful, enlarged (nonspecific lymphadenitis).

In the peripheral blood - changes corresponding to the picture of an acute inflammatory process: leukocytosis, in the leukocyte formula, a shift to the left, accelerated ESR. Blood changes may or may not be observed.

The infectious-allergic genesis of the disease can be schematically represented as follows: previously transferred diseases of coccal nature (patients with erythema multiforme exudative erythema have a history of tonsillitis, furunculosis), as well as concomitant pathology in the form of foci of chronic infection of various localizations gradually lead to an increase in the sensitivity of the body, changing and perverts its adaptive mechanisms. Against the background of the altered reactivity of the body, the listed provoking factors can cause a hyperergic reaction, clinically manifested by erythema multiforme exudative.

The plan of the clinical examination of the patient should include:

1) clinical analysis of blood and urine;

2) determination of the sensitivity of microflora from lesions to antibiotics;

3) skin-allergic tests with bacterial allergens;

4) according to indications - roentgenoscopy of the chest;

5) X-ray examination of the bite to identify foci of odontogenic infection;

6) examination of organs and systems in order to identify foci of chronic inflammation.

Clinical symptoms of organ pathology make it necessary to involve other specialists in the examination of patients.

Diagnosis of multiform exudative erythema

With an isolated lesion of the oral mucosa, the diagnosis of exudative erythema multiforme is difficult, since it has similarities with a number of diseases.

For the diagnosis of toxic-allergic form of exudative erythema multiforme caused by drugs, as well as to detect hypersensitivity to various allergens, immunological research methods are used: Shelley basophil degranulation tests, lymphocyte blast transformation test and cytopathic effect. It should be borne in mind that reliable data can only be obtained when all three tests are performed, since each of them reveals different aspects of immune disorders underlying delayed-type hypersensitivity, the manifestation of which is the toxic-allergic form of exudative erythema multiforme.

Erythema multiforme should be differentiated from pemphigus, acute herpetic stomatitis, drug-induced stomatitis (Table).

Limited forms of erythema multiforme exudative may resemble syphilitic papules, but there is always infiltration at the base of the latter. Hyperemia around papules, including eroded ones, looks like a narrow rim sharply limited from a healthy mucous membrane, while with exudative erythema, inflammation is not only more intense, but also much more widespread. In scrapings from the surface of syphilitic papules, pale treponemas are found, the Wasserman reaction and RIT in syphilis are positive.

Differential diagnosis of erythema multiforme exudative

Thus, exudative erythema multiforme is distinguished from herpetic stomatitis by a more widespread nature of the lesion, the absence of a herpetiform arrangement of rashes and a polycyclic outline of erosions that form after opening of the blisters, and the absence of herpetic cells in smears-imprints (scrapings).

Unlike pemphigus, exudative erythema multiforme has an acute onset with rapid dynamics of rashes, with it blisters persist for some time, located on an inflamed background, Nikolsky's symptom is negative, there are no acantholytic Tzank cells in smears-imprints.

Stevens-Johnson syndrome bears some resemblance to Lyell's syndrome, which occurs as the most severe form of drug-induced disease. This syndrome, in contrast to the Stevens-Johnson syndrome, is accompanied by extensive necrolysis of the epidermis and epithelium in the mouth, the rash resembles a III degree burn. On the oral mucosa in Lyell's syndrome, extensive areas of necrosis and erosion of the epithelium on the hard and soft palate, gums, and cheeks are observed. On the edge of bright red erosions there were grayish-white freely hanging fragments of the epithelium. The mucous membrane around the erosions has a normal appearance. Nikolsky's symptom in patients with Lyell's syndrome is positive. In smears taken from the surface of erosions, with Lyell's syndrome of drug etiology, acantholytic cells are often found, very similar to those in pemphigus vulgaris.

With benign non-acantholytic pemphigus of the oral mucosa, the clinical picture is characterized by periodic rashes of tense blisters only in the oral cavity, as well as the presence of erosions formed in their place, covered with either a gray-white fibrinous coating, or fragments of the bladder cover. The contents may be either serous or hemorrhagic. Localization of rashes for a long time can be in the same area of ​​the oral mucosa, more often in the soft and hard palate or cheeks. Sometimes the lesion is localized only on the gums, in some cases - on a brightly hyperemic base. Unlike multiform exudative erythema, there is no acute onset of the disease, temperature reaction, seasonality, damage to other mucous membranes and skin.

The presence of cicatricial adhesive or atrophic changes at the site of previously existing rashes is a reliable diagnostic sign in the differential diagnosis of exudative erythema multiforme with atrophic bullous dermatitis of Port Jacob, which primarily affects the mucous membranes of the eyes and oral cavity, as well as the esophagus and genital organs. In place of the blisters, painless erosions and ulcers are formed, which do not tend to increase in size, which are scarred, which leads to fusion of the mucous membranes in contact with each other.

Acantholytic cells are not found in smears-imprints. There are no signs of acute inflammation.

Treatment of erythema multiforme exudative

Each patient with MEE should be examined to identify chronic foci of infection in him, which are located in the maxillofacial region.

Treatment includes sanitation of the oral cavity, elimination of foci of infection. Anti-inflammatory therapy: sodium salicylate, acetylsalicylic acid 0.5 - 4 times a day - the drugs have an inhibitory effect on the biosynthesis of inflammatory mediators (histamine, serotonin, bradykinin, prostaglandins).

Desensitizing therapy: suprastin 0.025, diphenhydramine 0.05, pipolfen 0.025 (1 tab. 3 times a day), tavegil 0.001 (1 tab. 2 times a day), phenkarol 0.025 (2 tab. 3 times a day), diprazine, histaglobulin 1, 2.3 ml for a course of 4-10 injections. The drugs inhibit or eliminate the action of histamine, reduce capillary permeability, swelling, hyperemia, itching.

Detoxification therapy: sodium thiosulfate 30% (10 ml IV No. 10-12 per course) has an antitoxic, anti-inflammatory, desensitizing effect (stimulates the synthesis of thiol enzymes).

Vitamin therapy: vitamins of groups B, C, nicotinic acid (1 ml of 1% solution of sodium nicotinate intramuscularly every other day No. 10; 1 ml of 5% solution of ascorbic acid No. 10 every other day). Vitamin C is involved in the regulation of redox processes, carbohydrate metabolism, blood clotting, tissue regeneration, the formation of steroid hormones, collagen synthesis, and the normalization of capillary permeability.

Antibiotic therapy (in severe cases) is aimed at eliminating or weakening the secondary microflora. It has an antibacterial effect on gram+ and gram-microflora (they disrupt the synthesis of microbial cell membrane protein): ampicillin 250-500 mg 4 times a day / m for 4-6 days, ampiox 0.2-0.4 4 times a day, oxacillin sodium, lincomycin 0.25 4 times a day, oletethrin 250,000 IU 4 times a day orally for 4-6 days.

Corticosteroids (in severe cases): prednisolone (triamcyclon, dexamethasone) 20-30 mg per day, from the beginning of epithelialization, the dose of prednisolone is reduced to 0.005 g once every 7 days, hydrocortisone. The drugs have anti-inflammatory, anti-allergic and desensitizing effects.

Exemption from work (depending on the severity of the process).

Diet (not irritating, anti-allergic) helps to increase the body's resistance. Elimination of products that have an allergic effect reduces the intensity of the allergization of the body.

Treatment in the interrecurrent period:

Special (specific) desensitizing therapy with staphylococcal toxoid according to the scheme;

Purification of blood plasma, phenkarol, histaglobulin, potassium preparations (asparkam, decaris - levomisole);

Sanitation of the oral cavity eliminates the pathogenic effect of secondary microflora, local irritating factors.

Local treatment of erythema multiforme exudative:

Anesthesia (applications, oral baths) - solutions of lidocaine 1-2%, trimecaine 3-5%, pyromecaine 2%, trimecaine with hexamethylenetetramine (1: 2), 10% suspension of anestezin in oil (peach, olive), pyromecaine ointment. Purpose - Eliminate pain during antiseptic treatment, eating. Mechanism of action: drugs reduce the sensitivity of nerve endings, disrupt the generation and conduction of excitation, bind to the axon membrane, preventing its depolarization and the penetration of sodium ions through it;

Antiseptic treatment - solutions of hydrogen peroxide 1%, potassium permanganate (1:5000), furacilin, ethacridine lactate (1:1000), chloramine 0.25%, chlorhexidine 0.06%, calendula tincture (1 tsp per glass of water ). The goal is to eliminate or weaken the influence of secondary microflora on the damaged oral mucosa. The preparations have weak antiseptic and deodorizing properties due to the release of molecular and atomic oxygen;

Anti-inflammatory therapy - corticosteroid ointments (prednisolone, hydrocortisone, flucinar, lorinden, polkortalon). The goal is to eliminate inflammation, reduce exudation. The drugs have anti-inflammatory, anti-allergic and desensitizing effects, reduce vascular permeability, inhibit all three phases of the allergic reaction, have a stimulating effect on metabolic processes, tissue regeneration;

Epithelial therapy (carried out after the elimination of the infectious factor) - an oil solution of vitamin A, rosehip oil, caratolin, tezan liniment 0.2%), solcoseryl (jelly, ointment), Unna paste, KF, methyluracil, chonsuride, actovegin, Vitadent, Acemin Purpose - to accelerate the epithelialization of erosions, tissue regeneration, improve metabolic processes in the oral mucosa Mechanism: drugs stimulate cell regeneration, affect cell membranes, accelerate tissue repair, affecting the mechanism of physiological transport of nutrients by oxygen, have a non-specific anti-inflammatory action, have an enveloping property;

In the presence of necrotic and fibrinous plaque - the use of proteolytic enzymes (immozymaze, deoxyribonuclease, ribonuclease, lysozyme). Local treatment of the affected areas of the mucous membrane is carried out in the form of applications of enzymes on gauze napkins for 15-20 minutes;

In the treatment of exudative erythema multiforme, it is advisable to use both individual herbal remedies and phytocomnosions. Positive results are observed when using an ointment with sage extract. Locally, the affected areas of the oral mucosa are treated in the form of applications on gauze napkins for 15-20 minutes twice daily. At home, the patient is prescribed rinsing with a solution of calendula (a teaspoon of tincture in a glass of warm water) before and after meals, a sparing diet and diphenhydramine inside. After 2 visits, the erosive surfaces are cleaned of plaque, after the 4th visit, epithelialization of the affected areas of the mucous membrane begins;

To eliminate inflammation on the mucous membrane, herbadont is used, which includes medicinal plants: St. John's wort, common yarrow, large plantain, nettle. These plants are rich in tannins, essential oils, provitamin A, vitamins C and K, nicotinic acid, trace elements, antimicrobial agents, and mineral salts. Therapeutic manipulations are carried out in the form of applications twice a day for 10 minutes, the first 6 visits daily, and the next every other day;

At home, patients are prescribed alternating rinses with an aqueous solution of tinctures of arnica, calendula and eucalyptus before and after meals. After 2 visits, the erosive surface is cleared of plaque, patients painlessly take food. After 3-4 visits, the affected areas of the oral mucosa are epithelialized.

To stop inflammation, you can also use a mixture of oak bark, St. John's wort, kelp, yarrow, plantain, chamomile, wild rose, elderberry flowers. It is necessary to prepare a cocktail from the mixture as follows: these plants are mixed in equal weight ratio and ground into powder, and then one tablespoon of the mixture is brewed with a glass of boiling water.

Physiotherapy erythema multiforme exudative :

Beams of a helium-neon laser, UV radiation No. 5, hyperbaric oxygenation. The goal is to accelerate the epithelialization of erosions, tissue regeneration, to increase the protective and compensatory mechanisms of the oral mucosa. Mechanism: stimulating effect on metabolic processes, tissue regeneration.

Erythema multiforme exudative is an acute disease of the skin and mucous membranes, characterized by polymorphic rashes. The disease has a tendency to relapse, manifesting itself in spring or autumn.

Erythema multiforme exudative occurs mainly in young people, and middle-aged people are also frequent patients.

The disease may be associated with some provoking causes:

• sensitization of the body to certain types of drugs;
• the presence of infectious diseases, against which the development of erythema occurs.

In the first case, a symptomatic, or toxic-allergic form of the disease is implied, in the second, an idiopathic, or infectious-allergic form. The latter occurs in 80% of cases, the toxic-allergic variant - in 20%.

Causes of erythema multiforme exudative

Modern dermatology is not ready to clearly identify the objective causes and mechanisms for the development of erythema multiforme exudative. It is known that approximately 70 percent of people have a specific focus of chronic infection: sinusitis, otitis media, chronic tonsillitis, pulpitis, pyelonephritis, periodontal disease and many other diseases, as well as hypersensitivity to antigens. In these patients, during an exacerbation of exudative erythema multiforme, a decrease in immunity is recorded. As a result, it was suggested that the onset and exacerbation of the disease are due to immunodeficiency, which develops rapidly against the background of focal infections in interaction with some complicating and provoking factors, namely:

• hypothermia;
• angina;
• SARS.

Often, erythema multiforme exudative is associated with herpes infections.

The main and common cause of the manifestation of the toxic-allergic form of the disease is intolerance to certain drugs:

• sulfonamides;
• barbiturates;
• tetracycline;
• amidopyrine and others.

In addition, the disease may manifest itself after the administration of serum or vaccine. From the point of view of allergology, erythema multiforme exudative is a mixed type of hyperreaction, combining signs of immediate and delayed types of hypersensitivity.

Symptoms of erythema multiforme exudative

The infectious-allergic variant of erythema multiforme exudative has an acute onset of the disease, characterized by the following symptoms:

• general malaise;
• elevated temperature;
• headache;
• pain in the muscles;
• sore throat;
• arthralgia;
• rashes after 1-2 days against the background of general changes.

In about five percent of cases, the disease is localized only on the mucous membrane of the oral cavity, and in one third of the cases, lesions of the skin and oral mucosa are noted. There are rare cases when multiform exudative eczema affects the mucous membranes of the genitals. After the rash appears, the general symptoms of the disease gradually disappear, but may persist for up to three weeks.

Rashes on the skin with this disease, as a rule, are located:

• in the back of the hands and feet;
• on the soles and palms;
• on the extensor areas of the elbows and forearms;
• in the areas of the legs and knees;
• in the genital area.

The rashes are reddish-pink edematous flat papules with clear boundaries. They grow rapidly, reaching from two millimeters to three centimeters in diameter. The central part of the papules sinks, and its color becomes blue. Blisters with bloody or serous contents may also appear here. In addition, the same bubbles appear on apparently healthy areas of the skin. The polymorphism of rashes is due to the fact that blisters, pustules and spots are present on the skin at the same time. In most cases, rashes are accompanied by burning, and sometimes itching.

In case of damage to the oral mucosa, elements of multiform exudative erythema are localized on the cheeks, lips and palate. At first, the rashes are areas of delimited or diffuse reddening of the mucosa, and after 1-2 days, blisters appear in areas of exudative erythema multiforme, which open after the next two to three days and form erosion. Merging, erosions capture the entire surface of the oral mucosa, covering it with a gray-yellow coating. When you try to remove the plaque, bleeding opens.

There are cases when erythema multiforme exudative affects the oral mucosa with several elements without any pronounced pain. But practice shows that sometimes extensive erosion of the oral cavity occurs, which does not give the patient the opportunity to eat food even in liquid form and talk. In this case, a person has bloody crusts on his lips that prevent the sick person from opening and closing his mouth normally and painlessly. These rashes begin to disappear after two weeks, and finally disappear after about a month. The whole process on the mucous membrane of the oral cavity can last for one and a half months.

Usually, the toxic-allergic form of exudative erythema multiforme does not have the initial general signs and symptoms. There may be an increase in body temperature immediately before the rash. The toxic-allergic form, according to the characteristics of the elements of the rash, practically does not differ from another form of erythema - infectious-allergic. It is widespread and fixed, in both cases, infectious rashes affect only the oral mucosa. And with a fixed variant of the disease during relapses of erythema multiforme exudative rashes appear in the same places, as well as in new ones.

This disease is characterized by a relapsing course with subsequent exacerbation in the autumn and spring periods. In the toxic-allergic form of the disease, seasonality does not play a special role, and in some cases, erythema multiforme exudative is characterized by a continuous course due to constantly recurring relapses.

Diagnosis of multiform exudative erythema

To diagnose the disease at the consultation of a dermatologist, it is necessary to carefully examine the rashes and dermatoscopy. When collecting an anamnesis, special attention should be paid to possible links with any infectious processes, as well as taking or administering drugs. To confirm the diagnosis of erythema multiforme exudative, as well as to exclude any other disease, it is necessary to take imprint smears from the mucous membrane and from the affected areas of the skin.

Erythema multiforme exudative differentiates with pemphigus, erythema nodosum, disseminated form of systemic lupus erythematosus. Several of the following factors allow separating erythema multiforme from pemphigus:

• rapid dynamics and change in the rash;
• negative reaction to Nikolsky's symptom;
• complete absence of acantholysis in smears-imprints.

If the patient has a fixed form of exudative erythema multiforme, a differential diagnosis should be made with syphilitic papules. Some of the signs identified during the study make it possible to exclude syphilis, these are:

• the complete absence of pale treponemas during the study of the dark field;
• negative reactions RPR, RIF and PCR.

Treatment of erythema multiforme exudative

Treatment, even in the acute period of the disease, depends entirely on the clinical manifestations of erythema multiforme exudative. For example, if a patient has frequent relapses, mucosal lesions, disseminated rashes and the manifestation of necrotic areas located in the center of the rash elements, then the patient is prescribed a single injection of 2 ml of diprospan.

If the patient has a toxic-allergic form, then the main task for applying further effective treatment of the disease is to determine and remove from the affected body the substance that provoked the occurrence of erythema multiforme exudative. For this, the patient is prescribed plenty of fluids, the use of diuretics and enterosorbents. In a situation where a case of a disease has occurred for the first time or an indication in the anamnesis of data on an independent rapid resolution of its relapses, the administration of diprospan, as a rule, is not required.

Regardless of the form of erythema multiforme exudative, the patient is prescribed desensitizing therapy and the following drugs:

• tavegil;
• suprastin;
• sodium thiosulfate;
• antibiotics.

The latter are used only for secondary infection of rashes.

Local treatment for erythema multiforme exudative is carried out by using applications consisting of antibiotics with proteolytic enzymes, as well as lubricating the affected skin with special antiseptics: a solution of furacilin or chlorhexidine. As a treatment, the use of corticosteroid ointments, which include antibacterial drugs - dermazoline or trioxazine, is allowed. In case of damage to the mucous membrane, it is necessary to use rinsing with Rotokan and chamomile decoction, as well as lubrication with sea buckthorn oil.

Prevention of recurrence of exudative erythema multiforme in infectious-allergic form is closely related to the detection and elimination of herpes infection and chronic infectious foci. To do this, the patient will need to consult a qualified otolaryngologist, urologist, dentist and other specialists.

With a toxic-allergic variant of exudative erythema multiforme, it is important to prevent taking a medication that provokes the disease.

Depending on the nature of the allergen, exudative erythema multiforme is divided into:

- infectious-allergic,

- toxic-allergic forms

Etiology

Etiological factors: in the infectious-allergic form of exudative erythema multiforme, patients are sensitized to bacterial and viral allergens. The source of sensitization are foci of chronic infection (tonsillitis, otitis media, sinusitis, cholecystitis). The factors provoking the onset of the disease and its relapses are hypothermia, overwork, exacerbation of chronic somatic diseases (tonsillitis, bronchitis, otitis media, etc.).

The cause of the toxic-allergic form is more often medications (antibiotics, NSAIDs, synthetic vitamins, etc.), as well as food and household allergens.

Pathogenesis

MEE is based on an immunocomplex reaction (type III), which is manifested by polymorphic rashes on the oral mucosa (OM) and skin. At the same time, 32% of patients have an isolated lesion of the oral mucosa and the red border of the lips, and 68% have a combined lesion of the skin and mucous membranes.

Clinical manifestations

Characterized by an acute onset, as in an infectious disease: body temperature rises to 39-40ºС, symptoms of intoxication of the body develop.

Typical complaints: pain, burning, soreness in the mouth, inability to eat, worsening of the general condition, the presence of rashes in the oral cavity and on the skin, etc.

Extensive erosive surfaces covered with fibrinous whitish or grayish-yellow coating are determined when viewed for oral mucosa. Scraps of blisters are observed along the edge of erosions, when sipping which detachment of healthy epithelium does not occur (negative symptom of Nikolsky). There is a primary polymorphism of rashes: papules, erythema, blisters and vesicles, after opening of which erosions and aphthae are formed).

In the oral cavity, rashes can vary in variability: hemorrhagic manifestations (bubbles with hemorrhagic exudate, hemorrhages, petechiae and bleeding of oral mucosa); ulcerative-necrotic (these lesions are caused by allergic alteration of the oral mucosa, the addition of a secondary infection, aggravated by poor hygiene and self-cleaning of the oral cavity due to pain, which leads to significant intoxication and the appearance of a putrid odor); catarrhal (erythema and edema of the mucous membrane).

The skin is characterized by maculopapular rash elements that slightly rise above the surrounding surface. The central part of the element subsequently, after opening the papule, sinks a little and acquires a bluish tint, while the peripheral part retains a pink-red color, forming a "cockade".

Favorite places for localization of rashes with erythema multiforme exudative: dorsal surfaces of the hands, feet, extensor surfaces of the forearms, shins, elbow and knee joints, palms and soles. A distinctive feature of the toxic-allergic form of exudative erythema multiforme is the absence of seasonal recurrences, in the anamnesis there is a connection with taking medications, after which a relapse occurs.

Stevens-Johnson Syndrome - severe form of MEE. At the same time, SO of the oral cavity, nose, eyes, genitourinary organs, zh.k.t. and skin coverings.

Lyell's syndrome or toxic epidermal necrolysis is the most severe form of MEE. At the same time, almost all COs are involved in the process, including internal organs, an extensive skin surface is affected with epidermal exfoliation, the formation of hemorrhagic blisters and subsequent erosion.

Nikolsky's symptom is positive only in the area of ​​blister formation. The course of the disease is continuous, relapsing, accompanied by dehydration, shock, secondary infection and septicemia.

Treatment of erythema multiforme exudative

Complex: general and local. In severe cases, hospitalization is required.

General treatment:

1. Elimination of possible allergens (medicinal, microbial, food, etc.), which includes consultation with an allergist, pediatrician, gastroenterologist and sanitation of chronic foci of focal infection);

2. Antihistamines I, II, III, IV generations orally (mild) or parenterally (moderate or severe);

3. Steroid hormones are indicated for moderate and severe forms;

4. Non-steroidal anti-inflammatory drugs are indicated for hyperergic reactions (body temperature over 38.5-39ºС);

5. Detoxification therapy: plentiful fortified drink, enterosorbents in mild and moderate forms. In severe cases - parenteral administration of physiological or plasma-substituting solutions to restore electrolyte balance;

6. Antibiotic therapy is prescribed strictly according to the indications for the infectious-allergic form and with the addition of a secondary infection.

In MEE, medications should be prescribed carefully, reasonably, guided by the indications and the dynamics of the process, in order to avoid polypharmacy and aggravate the severity of the child's condition.

Local treatment:

application anesthesia (gel kamistad, 3% suspension of anesthesin in peach or other indifferent oil);

antiseptic treatment (solutions of furacilin, furagin, hydrogen peroxide, givalex, stomatidine, etc.);

preparations of proteolytic enzymes to eliminate necrotic tissues (trypsin, chymotrypsin, Iruksol ointment);

rutin-containing preparations for softening and eliminating hemorrhagic crusts (gels venoruton, troxerutin, troxevasin);

herbal anti-inflammatory drugs (calendula, chamomile, yarrow, Romazulan, Rotokan) or corticosteroid ointments (Flucinar, Aurobin);

topical antihistamines (fenistil gel, psilobalm, decoction, infusion or string oil);

keratoplastic agents (oily solutions of vitamins A, E, carotenoline, rosehip oil, sea buckthorn, jelly and solcoseryl ointment).

Erythema multiforme exudative is a disease of the epidermal layer or the surface of the mucous membranes in an acute form. Skin rashes are a key characteristic of the disease. This pathology appears equally often in both children and adults, depending on the causes. Exacerbations occur in autumn and spring.

Why does the disease appear

There are certain factors that predispose to the occurrence of erythema multiforme exudative in children and adults. Among them, the body's addiction to long-term use of certain medications, as well as an endogenous factor - chronic infectious processes in the body.

The first case is characterized by such a form of exudative erythema multiforme as symptomatic (toxic-allergic). The second option is called the infectious-allergic form of erythema..

Important! Case histories of exudative erythema multiforme indicate that more than 70% of patients are diagnosed with an infectious-allergic type of disease.

• inflammation of the maxillary sinuses - sinusitis;
• inflammatory process of the middle ear - otitis media;
• inflammation of the tonsils in the throat - tonsillitis;
• inflammation of the tissues of the tooth - pulpitis;
• chronic inflammation of the urinary system - cystitis, pyelonephritis.

Important! The reason for the development of erythema multiforme can be a decrease in immunity against the background of hypothermia, tonsillitis, acute respiratory viral infections, herpes.

The toxic-allergic form is due to intolerance to certain medications, which include sulfonamides, tetracycline antibiotics, barbiturates, amidopyrine, salicylates, etc..

Sometimes exudative erythema develops against the background of the introduction of serum or vaccine. In this case, the disease is a hyperreaction of a mixed type.

Important! One of the severe complications of exudative erythema multiforme is Stevens-Johnson syndrome (malignant erythema). During it, detachment of the epidermis occurs.

Clinical picture of the disease

The infectious-allergic form of the disease is characterized by an acute onset and the occurrence of the following symptoms:

1. General malaise.
2. Hyperthermia.
3. Headache.
4. Muscle and joint pain.
5. Pain in the throat.
6. The rash appears a day or two after the onset of the disease.

More often, rashes are located on the surface of the skin, sometimes on the mucous membrane of the oral cavity or genital organs. After the rash appears, the general clinical manifestations persist for up to two weeks, gradually decreasing in intensity..

On the skin, the rash can be located:

• on the hands and feet;
• on the soles and surfaces of the palms;
• on the inside of the elbows and knees;
• on the calves.

The rash is a well-defined pink or red papules, accompanied by swelling. They are prone to rapid growth, their diameter is sometimes up to three centimeters. As the disease progresses, the center of the papules begins to sink, turning blue. In their place, blisters begin to appear with exudate from the blood or serous fluid. Similar formations begin to appear on the healthy surface of the epidermis. The rash is accompanied by burning or intense itching.

Important! The multiformity of exudative erythema is associated with the simultaneous appearance of blisters, spots and papules on the skin.

If the oral mucosa is affected, the rashes are located on the inner surface of the cheeks, lips and in the sky. At first, the affected areas look like a blurred redness, after two days papules appear on the affected areas, which open up after a few more days, erosion remains in their place. These formations merge into one large erosion, which is covered with a grayish coating on top. If a person tries to remove this plaque, the sores begin to bleed.

Therapeutic activities

One of the directions of therapy is the use of antihistamines.

Treatment of erythema multiforme exudative is directly dependent on the severity of symptoms and the form of the disease.

In severe infectious-allergic form with frequent relapses, the patient is shown a single injection of Diprospan.

Important! If a sick person suffers from a toxic-allergic form of the disease, the key focus of therapy is to identify and remove the irritant substance from the body, which provoked an exacerbation of the disease.

Regardless of which form of the disease is diagnosed, desensitizing therapy is used using antihistamines (Tavegil, Suprastin, Claritin, etc.), sodium thiosulfate.

In case of infection of the rashes, antibacterial drugs are used.

Local treatment includes the use of applications on the affected areas; for this, antibiotics with proteolytic enzymes are used. The affected area of ​​the skin is also lubricated with antiseptic substances (Furacilin, Chlorhexidine, etc.).

For therapy, corticosteroid ointments are also used (as prescribed by a doctor).

If the mucous membrane of the oral cavity is affected, rinsing with Rotokan is prescribed. Also, the affected areas in the mouth are treated with sea buckthorn oil or Chlorophyllipt.

Treatment of folk remedies for erythema multiforme exudative can act as an adjuvant therapy after prior consultation with a doctor. Treatment only with the help of folk remedies is unacceptable, it is fraught with aggravation of the condition.

In order to prevent recurrence of the toxic-allergic form of erythema, uncontrolled use of drugs should be avoided. Prevention of infectious-allergic erythema consists in the timely treatment of infectious diseases and the intake of immunomodulators.