Definition And Description

Willan, the father of English dermatology, described certain cutaneous affections under the titles Erythema marginatum, E. papulatum, and E. tuberculatum; later writers added to these the expressions E. carcinatum. E. vesiculosum, etc. Hebra has properly, we think, included them all under the general name of Erythema multiforme, implying an erythematous affection of multiple lesion.

The eruption may consist of patches of redness, over which circum-scribed elevations also red are scattered. These elevations may be few or plentiful, and may vary from one-eighth to three-fourths of an inch or more in diameter. The small ones may, according to size, be called papules or tubercles, while the larger ones, which are always flattened, may assume the appearance of an elevated ring, around which a second or third ring may develop.

These various lesions rarely persist more than a week or ten days, at the end of which time they gradually subside and disappear, leaving after them bluish stains which last a few days longer. After the disappearance of the first eruption, or even while it is still in full efflorescence, a second crop of lesions may come out, and after this a third, prolonging the trouble in this way for several weeks or months. The eruption may consist simply of papules or of tubercles, or more frequently several or all of the lesions mentioned above may coexist in varying proportions. The favorite seats of Erythema multiforme are the backs of the hands, wrists, the feet and ankles. The eruption, however, may occur upon any part of the surface, and sometimes becomes quite general.

The outbreak of E. multiforme is sometimes characterized by prodro-mata of a mild febrile character, which exist for a day or two before the appearance of the cutaneous lesions, and subside as the latter develop. The subjective local symptoms are slight, and may consist in a little burning or itching at the seat of the cruption, but rarely sufficiently intense to cause much inconvenience. The eruption is more frequent in spring and autumn than at other seasons, and in some individuals exhibits a tendency to recur at these times.

Diagnosis

The diagnosis of Erythema multiforme is, as a rule, not difficult. The polymorphic character of the lesion, and its usually local- ized distribution, serve to distinguish it from other cutaneous eruptions. Not unfrequently the lesions possess a livid or cyanotic aspect, due to stasis, not hemorrhage, that, taken in connection with the annular form of the larger lesions, is quite characteristic.

Prognosis

The prognosis in this affection is almost always favorable. Recent cases, that is, of a few days' standing, may usually be brought to a speedy termination, and relapses may generally be broken up. In the majority of cases the eruption would probably run its course without treatment in a month or six weeks, but we have met with instances in which it had persisted for two or three months, finally disappearing under treatment.

Etiology

In some cases the eruption seems to be attributable to errors of diet; in others it appears subsequent to some traumatism and in not a few it is impossible to discover anything that may be fairly regarded as standing in a causative relation. The more carefully, however, we have studied these cases, the more we are impressed with the idea that Erythema multiforme is usually a reflex affection, and closely allied to Urticaria. In two or three cases that have fallen under observation, malarial influences appeared to be at work.

Treatment

For the last few years we have adopted the following plan of treatment (the same that we recommend in acute urticaria) with very satisfactory results. In adults, from five to ten drops of the fluid extract of Ipecac are given every ten minutes until the patient vomits. As soon as his stomach is calmed down a little and the patient feels capable of the requisite exertion, he is placed in a Turkish bath until he sweats freely. He is then shampooed in the usual manner, dried off, and put to bed. The next day another Turkish bath is taken, and, if necessary, a third. In one instance we have known the efflorescence to disappear while the patient was taking his first bath, and no further eruption occurred. In default of the Turkish bath, a wet pack or a full dose of Jaborandi might be tried. In cases of longer standing apparent benefit has followed the use of belladonna, pushed until physiological effects are developed, and quinine in full doses. Several years ago, in a case then under my care, coffee appeared to be the exciting cause, and relinquishment of this beverage was followed by permanent disappearance of the eruption. In a few cases of this sort the cause of the trouble can be discovered, and rational treatment be adopted; in many, however, this cannot be done, and we must either try purely empirical treatment or give a placebo, and wait for a spontaneous recovery.