Oral erythema multiforme: clinical observations and treatment of 95 patients

Occurrence of erythema multiforme following COVID-19 vaccination: a review

The fast development of vaccines against the novel coronavirus disease is among the most critical steps taken to control this potentially fatal viral disease. Like other vaccines, the coronavirus disease 2019 (COVID-19) vaccines can also cause unwanted reactions. Erythema multiforme (EM) is among the oral mucocutaneous side effects of COVID-19 vaccines. This study aimed to comprehensively review the reported cases of EM since the global onset of COVID-19 vaccination. Data from 31 relevant studies regarding the type and dose of COVID-19 vaccines administered, time of initiation of symptoms, age, and gender of patients, site of involvement, patients' medical history, and treatment options were extracted. In total, 90 patients were identified with EM as a side effect of COVID-19 vaccination across studies. EM had the highest frequency after receiving the first dose of mRNA vaccines in older individuals. The first symptoms of EM appeared in less than 3 days in 45% and after 3 days in 55% of patients. EM is not a common side effect of COVID-19 vaccination, and fear of its occurrence should not impede vaccination.

A review and guide to drug-associated oral adverse effects-Oral mucosal and lichenoid reactions. Part 2

Dental practitioners and other health professionals commonly encounter and manage adverse medicine effects that manifest in the orofacial region. Numerous medicines are associated with a variety of oral adverse effects. However, due to lack of awareness and training, these side effects are not always associated with medicine use and are underreported to pharmacovigilance agencies by dentists and other health professionals. This article aims to inform health professionals about the various oral adverse effects that can occur and the most commonly implicated drugs to improve the management, recognition and reporting of adverse drug effects. This article follows on from Part 1; however, the focus here is on lichenoid reactions and oral mucosal disorders including oral aphthous-like ulceration, mucositis and bullous disorders such as drug-induced pemphigus, pemphigoid, Stevens-Johnson syndrome and toxic epidermal necrolysis.

Painful Oral Lesions

Painful oral vesiculoerosive diseases (OVD) include lichen planus, pemphigus vulgaris, mucous membrane pemphigoid, erythema multiforme, and recurrent aphthous stomatitis. OVD lesions have an immunopathic cause. Treatment is aimed at reducing the immunologic and the following inflammatory response. The mainstay of OVD management is topical or systemic corticosteroids to include topical triamcinolone, fluocinonide, and clobetasol, whereas systemic medications used in practice can include dexamethasone, prednisone, and prednisolone. Oral herpetic lesions can be primary or recurrent. If management is desired, they can be treated by topical or systemic antiviral drugs. Topical antiviral creams include prescription acyclovir, penciclovir and over-the-counter docosanol.

From HSV infection to erythema multiforme through autoimmune crossreactivity

Scientific and clinical data indicate that human herpes simplex virus 1 (HSV1) and, at a lesser extent, human herpes simplex virus 2 (HSV2) are factor(s) implicated in the development of erythema multiforme (EM). With a focus on oral EM, the present structured review of proteomic and epitope databases searched for the molecular basis that might link HSV1 and HSV2 infections to EM. It was found that a high number of peptides are shared between the two HSVs and human proteins related to the oral mucosa. Moreover, a great number of the shared peptides are also present in epitopes that have been experimentally validated as immunopositive in the human host. The results suggest the involvement of HSV infections in the induction of oral EM via a mechanism of autoimmune cross-reactivity and, in particular, highlight a potential major role for 180kDa bullous pemphigoid antigen and HSV1 infection in the genesis of crossreactions potentially conducive to EM.

Fuchs Syndrome: Medical Treatment of 1 Case and Literature Review

Fuchs syndrome is a particular type of erythema multiforme major; the lesions are only found on the mucosae and specifically affect oral, ocular, and genital mucosae. The cause is not always immediately apparent, which is why this pathology requires a rigorous, detailed clinical examination to eliminate a differential diagnosis. The severity of the symptoms, particularly of oral and ocular symptoms, requires immediate treatment. The treatment of this pathology requires a multiple-drug regime. Through a clinical case study, the objective of this work is to help guide practitioners when diagnosing and treating this pathology as no current consensus exists on these 2 subjects. The authors present the case of a 29-year-old patient who was suffering from a recurring outbreak of Fuchs syndrome, suspected of having been triggered by Mycoplasma pneumoniae. After completing the treatment program based on colchicine and prednisolone, the patient was relieved from pain and has not suffered from any further periodic eruptions of erythema multiforme.

Acute periodontal lesions

This review provides updates on acute conditions affecting the periodontal tissues, including abscesses in the periodontium, necrotizing periodontal diseases and other acute conditions that cause gingival lesions with acute presentation, such as infectious processes not associated with oral bacterial biofilms, mucocutaneous disorders and traumatic and allergic lesions. A periodontal abscess is clinically important because it is a relatively frequent dental emergency, it can compromise the periodontal prognosis of the affected tooth and bacteria within the abscess can spread and cause infections in other body sites. Different types of abscesses have been identified, mainly classified by their etiology, and there are clear differences between those affecting a pre-existing periodontal pocket and those affecting healthy sites. Therapy for this acute condition consists of drainage and tissue debridement, while an evaluation of the need for systemic antimicrobial therapy will be made for each case, based on local and systemic factors. The definitive treatment of the pre-existing condition should be accomplished after the acute phase is controlled. Necrotizing periodontal diseases present three typical clinical features: papilla necrosis, gingival bleeding and pain. Although the prevalence of these diseases is not high, their importance is clear because they represent the most severe conditions associated with the dental biofilm, with very rapid tissue destruction. In addition to bacteria, the etiology of necrotizing periodontal disease includes numerous factors that alter the host response and predispose to these diseases, namely HIV infection, malnutrition, stress or tobacco smoking. The treatment consists of superficial debridement, careful mechanical oral hygiene, rinsing with chlorhexidine and daily re-evaluation. Systemic antimicrobials may be used adjunctively in severe cases or in nonresponding conditions, being the first option metronidazole. Once the acute disease is under control, definitive treatment should be provided, including appropriate therapy for the pre-existing gingivitis or periodontitis. Among other acute conditions affecting the periodontal tissues, but not caused by the microorganisms present in oral biofilms, infectious diseases, mucocutaneous diseases and traumatic or allergic lesions can be listed. In most cases, the gingival involvement is not severe; however, these conditions are common and may prompt an emergency dental visit. These conditions may have the appearance of an erythematous lesion, which is sometimes erosive. Erosive lesions may be the direct result of trauma or a consequence of the breaking of vesicles and bullae. A proper differential diagnosis is important for adequate management of the case.

Erythema multiforme major following treatment with infliximab

BACKGROUND

The growth in the use of anti-tumor necrosis factor α (TNF-α) agents for treatment of inflammatory conditions has led to increased recognition of the side effects associated with this class of drugs.

CASE DESCRIPTION

We report a case of a patient who developed erythema multiforme (EM) major with characteristic oral and cutaneous lesions following treatment with the anti-TNF-α medication infliximab therapy for Crohn's disease (CD).

CLINICAL IMPLICATIONS

To our knowledge, this is the first reported case of infliximab-induced EM secondary to the treatment of CD. It is important for dental clinicians evaluating patients using anti-TNF-α agents to be aware of this possible complication.

Erythema multiforme and related disorders

Erythema multiforme (EM) and related disorders comprise a group of mucocutaneous disorders characterized by variable degrees of mucosal and cutaneous blistering and ulceration that occasionally can give rise to systemic upset and possibly compromise life. The clinical classification of these disorders has often been variable, thus making definitive diagnosis sometimes difficult. Despite being often caused by, or at least associated with, infection or drug therapy, the pathogenic mechanisms of these disorders remain unclear, and as a consequence, there are no evidence-based, reliably effective therapies. The present article reviews aspects of EM and related disorders of relevance to oral medicine clinical practice and highlights the associated potential etiologic agents, pathogenic mechanisms and therapies.

[Acquired bullous diseases of the oral mucosa]

Bullous diseases of the oral cavity cause painful erosion. They must be distinguished from aphthae and vesicles which may have a similar presentation. Acute, chronic and congenital conditions are recognized. Acute lesions may involve a polymorphous oral erhythema which has an polymorphous erythematous presentation or toxidermia (Stevens-Johnson syndrome, Lyell syndrome, fixed pigmented erythema). Examination of the skin and history taking are the keys to diagnosis. Patients with chronic bullous diseases may have a congenital condition (bullous epidermolysis or lymphangioma) suggested by the age at onset and the clinical presentation. Acquired chronic bullous diseases include lichen planus and autoimmune bullous diseases. Careful examination is essential to identify mucosal or cutaneous involvement and to obtain a biopsy for histological examination. Search for antibodies deposited in the perilesional mucosa is necessary. Chronic erosive gingivitis is a frequent presentation. Most of the patients have cicatricial pemphigoid, lichen planus, and more rarely pemphigus. The pinch sign is highly discriminative to differentiate the cause of this syndrome. Symptomatic treatment of bullous lesions of the oral cavity include adapted diet and correct and early use of antalgesics.

Oral pemphigus vulgaris in children and adolescents: a review of the literature and a case report

This paper describes a case of oral pemphigus vulgaris (PV) in a child that was diagnosed in its early stages and managed successfully. The authors also report a literature review. Although oral PV in children and adolescents is extremely rare, it should be included in the differential diagnosis of oral ulcerative disease. It is of utmost importance to diagnose PV in children and adolescents in its initial stages in order to prevent the serious morbidity that may result from the disease, and to institute phamacotherapeutic measures so that they have the greatest effect. Furthermore, it is essential for dentists to be aware of the existence of PV in child and adolescent patients so that they may refer such cases for specialist management without undue delay.

Levamisole in dermatology : a review

Levamisole, an anthelmintic agent with a wide range of immunomodulatory actions, has been used successfully as monotherapy and an adjunct to treatment in a variety of diseases. Since 1990, combination therapy of levamisole and fluorouracil has played an important role in the treatment of resected Dukes stage C adenocarcinoma of the colon. Because of its immunomodulating effects levamisole has been used in a wide range of diseases with and without success. In dermatologic disease levamisole has been successfully used in the treatment of parasitic, viral and bacterial infections including leprosy, collagen vascular diseases, inflammatory skin diseases and children with impaired immune a variety of reasons. It has also been used in combination with other drugs for treating a number of dermatologic disorders, e.g. in combination with cimetidine for treating recalcitrant warts, with prednisolone for treating lichen planus, erythema multiforme and aphthous ulcers of the mouth. Adverse affects of levamisole are mild and infrequent and include rash, nausea, abdominal cramps, taste alteration, alopecia, arthralgia, and a flu-like syndrome. It can rarely cause agranulocytosis. More studies need to be undertaken to study the full potential of levamisole in dermatologic diseases.

Oral manifestations of erythema multiforme

Erythema multiforme is a reactive mucocutaneous disorder in a disease spectrum that comprises a self-limited, mild, exanthematic, cutaneous variant with minimal oral involvement (EM minor) to a progressive, fulminating, severe variant with extensive mucocutaneous epithelial necrosis (SJS and TEN). Significant differences exist among EM minor, EM major, SJS, and TEN with regards to severity and clinical expression; however, all variants share two common features: typical or less typical cutaneous target lesions and satellite-cell or more widespread necrosis of the epithelium. These features are considered to be sequelae of a cytotoxic immunologic attack on keratinocytes expressing non-self-antigens. These antigens are primarily microbial (viruses) or drugs and in rare instances histocompatibility antigens [5]. Although the precise pathogenesis is unknown, there is a tendency to consider EM both minor and major as part of one spectrum that is most often triggered by viral infections, and SJS and TEN as a separate one most often elicited by drugs with EM major and SJS representing a bridge in the continuum of EM. The oral manifestations of the spectrum of EM range from tender superficial erythematous and hyperkeratotic plaques to painful deep hemorrhagic bullae and erosions. Other mucosal surfaces including ocular, nasal, pharyngeal, laryngeal, upper respiratory, and anogenital may be involved. Scarring sequelae from ocular and pharyngeal involvement cause morbidity. The oral EM variant is an underrecognized form of EM. Most patients have chronic or recurrent oral lesions only, but one third have oral and lip lesions and one quarter have oral, lip, and skin lesions. This variant is a reaction pattern similar to EM minor, EM major, SJS, and TEN. The diagnosis of oral EM is one of exclusion. Careful clinical evaluation for other chronic mucocutaneous diseases, such as pemphigus, paraneoplastic pemphigus, mucous membrane pemphigoid, and lichen planus, is a necessary component of the diagnosis. The value of a biopsy specimen studied by both routine histopathologic and immunopathologic methods is fundamental to excluding the other causes for this variant of EM.

Complement C4 deficiency and HLA homozygosity in patients with frequent intraoral herpes simplex virus type 1 infections

Three consecutive patients with no apparent immunodeficiency who had frequent intraoral herpes simplex type 1 recurrences, a rare complication of herpes simplex virus infection, were found to have a total deficiency of either the A or B isotype of the complement component C4 and to be homozygous for the studied HLA antigens. A combination of HLA homozygosity, which may lead to impaired T cell recognition of viral peptides, and deficiency in the classical complement pathway, which can compromise virus neutralization, may predispose to severe and frequent herpes simplex virus infections.

Cinnamon-induced oral erythema multiformelike sensitivity reaction

BACKGROUND

Erythema multiforme, or EM, is a hypersensitivity reaction to agents such as herpes virus, drugs or foods. Oral EM-like reactions may be induced by cinnamon. It is important for dentists to recognize this condition.

CASE DESCRIPTION

The authors report an unusual case of cinnamon-induced oral EM-like reaction in an older female patient. The disease manifested itself as chronic extensive surface ulcerations and lip swelling. The patient was treated repeatedly with topical and systemic steroids but responded to them only temporarily. The patient was cured when the offending agent--cinnamon--was eliminated from her diet.

CLINICAL IMPLICATIONS

Oral EM or EM-like reactions pose a diagnostic dilemma due to their varied etiologies and clinical manifestations. Correct diagnosis is essential for effective treatment. A negative skin test does not rule out an allergic reaction to food.

Non-plaque-induced gingival lesions

The origin of gingival inflammation is occasionally different from that of routine plaque-associated gingivitis, and such non-plaque-associated types of gingivitis often present characteristic clinical features. Examples of such forms of gingivitis are specific bacterial, viral, and fungal infections. Specific bacterial infections of gingiva may be due to Neisseria gonorrhea, Treponema pallidum, streptococci, and other organisms. The most important viral infections of gingiva are herpes simplex virus type 1 and 2 and varicella-zoster virus. Fungal infections may be caused by several fungi, the most important of these being Candida species including C. albicans, C. glabrata, C. krusei, C. tropicalis, C. parapsilosis, and C. guillermondii. Gingival histoplasmosis is a granulomatous disease caused by the fungus Histoplasma capsulatum and, as for the other specific infections of gingiva, a confirmed diagnosis may require histopathologic examination and/or culture. Atypical gingivitis may also occur as gingival manifestations of dermatological diseases, the most relevant of these being lichen planus, pemphigoid, pemphigus vulgaris, erythema multiforme, and lupus erythematosus. Non-plaque induced gingival inflammation can be caused by allergic reactions to dental restorative materials, toothpastes, mouthwashes, and foods. In addition, gingival inflammation may result from toxic reactions, foreign body reactions, or mechanical and thermal trauma.

Lip adhesion: an unusual complication of erythema multiforme

The purpose of this article is to report a case of lip adhesion as a complication of erythema multiforme in an 8-year-old child. This is the second reported case of this complication of oral ulceration associated with erythema multiforme.

Response to levamisole and low-dose prednisolone in 41 patients with chronic oral ulcers: a 3-year open clinical trial and follow-up study

OBJECTIVE

The purpose of this open clinical trial and follow-up study was to evaluate the short-term and long-term clinical efficacy of levamisole used with low-dose prednisolone in 30 patients with oral lichen planus, 6 patients with erythema multiforme, 3 patients with mucous membrane pemphigoid, and 2 patients with early pemphigus vulgaris.

STUDY DESIGN

All patients were given 150 mg/day of levamisole and 15 mg/day of prednisolone for 3 consecutive days each week, along with topically applied dexamethasone orobase (dexaltin).

RESULTS

Twenty-three patients showed dramatic remission of signs and symptoms within 2 weeks; 18 patients experienced partial remission. Forty patients reported significant pain relief, and almost none showed evidence of oral ulcerative lesions after 4 to 8 weeks of treatment. In contrast, 1 patient with oral lichen planus with allergy to levamisole reported a partial response from prednisolone alone. All 29 patients with oral lichen planus remained free from symptoms for more than 6 months. All 6 patients with erythema multiforme, all 3 patients with mucous membrane pemphigoid, and both patients with pemphigus vulgaris also remained free from symptoms for 2 to 3 years. There were few side effects from the treatment; there was minor skin rash from levamisole in 1 case of oral lichen planus. We also designed a flexible plastic carrier for topically applied dexaltin in the treatment of diffuse atrophic or ulcerative gingivitis.

CONCLUSIONS

The addition of levamisole to prednisolone may produce improved results in the management of erosive lichen planus, erythema multiforme, mucous membrane pemphigoid, and early pemphigus vulgaris.

The clinical spectrum of desquamative gingivitis

Desquamative gingivitis is a fairly common complaint. Typically seen in females who are middle-aged or older, it is predominantly a manifestation of a range of vesiculobullous disorders. The main complaint is of persistent soreness of the gingiva. Most cases are related to lichen planus or pemphigoid, but it is also important to exclude pemphigus, dermatitis herpetiformis, linear IgA disease, chronic ulcerative stomatitis, and other conditions. Biopsy is invariably required to confirm the diagnosis after a full history, general, and oral examination. Apart from improving the oral hygiene, immunosuppressive therapy is typically required to control the condition.

Apoptosis in oral erythema multiforme

OBJECTIVE

Cell death was evaluated in oral erythema multiforme to test the hypothesis that apoptosis may be a mechanism by which keratinocytes die in this condition.

STUDY DESIGN

Ten erythema multiforme and five control oral mucosa biopsy specimens were evaluated in immunohistochemically stained sections for apoptosis-regulating proteins Bcl-2, Bcl-x, Bax, p53, Fas, and Fas-ligand. Apoptotic keratinocytes, determined by a detection method for DNA fragmentation (TUNEL) and by conventional morphologic criteria were counted per high power field.

RESULTS

Keratinocyte staining for Bcl-2 protein was comparable in erythema multiforme and controls. Bcl-x expression was reduced in five erythema multiforme cases. Staining for Bax protein differed in six erythema multiforme cases and showed variable intensity in layers under the parakeratin. Only slight differences in staining patterns of Fas and Fas-ligand proteins were noted between erythema multiforme and controls. The number of apoptotic keratinocytes evaluated by morphologic examination was significantly higher in erythema multiforme (mean per high power field, 0.90 +/- 0.2; controls, 0.06 +/- 0.04; p < 0.05, Mann-Whitney test) and was limited in significance by the TUNEL method (erythema multiforme, 0.43 +/- 0.1; controls, 0.02 +/- 0.02). Overexpression of p53 protein was seen in basal keratinocytes in five erythema multiforme specimens (mean, 17.5 +/- 4.03 per high power field; controls 1.2 +/- 0.3).

CONCLUSIONS

There is evidence that cell death in erythema multiforme is at least in part due to apoptosis. The apoptotic mechanism may be related to an altered expression of apoptosis-regulating proteins. Although measurable alterations in the phenotypic expression of Fas and Fas-ligand proteins were not apparent, activation of Fas/Fas-ligand system could still be involved in the induction of apoptosis in erythema multiforme.

Altered expression of epithelial integrins and extracellular matrix receptors in oral erythema multiforme

Inflammation and ulceration at the epithelium-connective tissue interface, a characteristic of erythema multiforme (EM), may be associated with altered molecular attachment of basal keratinocytes. To determine the expression of basal keratinocyte-associated integrins and their basement membrane ligands in oral EM, specimens of clinically and microscopically confirmed EM (n = 12) and mucosal controls (n = 7) were stained immunohistochemically for the integrins alpha 3, beta 6, beta 1, and beta 4 and for extracellular matrix proteins laminin 1, laminin 5, collagen IV, and collagen VII using a standard avidin-biotin-peroxidase technique. In EM, results showed increased staining intensity for all integrins studied in basal and suprabasal keratinocytes. Basement membrane-associated staining of a6 and b4 was intense, but disrupted and fragmented. In EM, integrin staining was most marked at the summit of the connective tissue papillae. Laminin 5 staining was more intense than in controls, was frequently fragmented, and extended into the lamina propria. Laminin 1 staining was discontinuous and was frequently less intense than in controls. Collagen IV staining in EM was interrupted along the basement membrane. Collagen VII staining was fragmented but unchanged in intensity. These alterations in interface adhesion molecules suggest that hemidesmosome-associated molecules are important in the pathogenesis of EM. The staining intensities and patterns of expression of these adhesion molecules suggest that oral EM is initially focused in the connective tissue papillae.

Viral infections in the immunocompetent patient

Human herpesviruses and human papillomaviruses are ubiquitous and may cause an array of oral disease. Herpesviruses are unique because recurrent localized disease occurs after the primary infection. Human papillomaviruses are known for their ability to produce benign epithelial proliferations and increasingly are implicated in the development of oral cancer. This article reviews the pathogenesis of common oral lesions induced by these viruses.

Lesions associated with drug reactions

Several of the more common oral lesions secondary to medication use have been presented in this article. Although some of these conditions are specific to the oral tissues, some are not. Numerous cutaneous reactions to medications have mucosal counterparts. It is important for the clinician to recognize that many oral lesions are simply a manifestation of a systemic condition and should be managed with that in mind.

Characteristics of the oral lesions in patients with cutaneous recurrent erythema multiforme

Erythema multiforme may be recurrent and the oral cavity is often affected. A series of 82 patients with unequivocal recurrent cutaneous erythema multiforme were examined to determine the incidence and nature of oral lesions. Seventy per cent of patients had oral lesions, comprising multiple, large, shallow, extremely painful and debilitating ulcers, which affected the entire oral mucosa in over 20%. The buccal mucosa and tongue were the most frequently affected sites in the remainder and the lips were affected in 13% of patients. Lesions generally lasted for 1-3 weeks. In over 60% of cases these attacks followed an episode of herpes simplex virus infection during the preceding fortnight. Recurrent attacks showed a different site distribution from the initial attacks, with a greater proportion having genital as well as skin and oral mucosal involvement. Detailed case histories of five patients are presented to illustrate the role of azathioprine in treating oral lesions and to document a familial case of recurrent erythema multiforme, with severe mucosal involvement.

Erythema multiforme involving gingiva

Erythema multiforme is a vesiculobullous condition that may affect skin and/or mucosa. Oral lesions are characterized by hemorrhagic crusting of the lips and ulceration mainly of the non-keratinized mucosa. This paper describes a patient who presented with gingival lesions as well as the more typical oral signs of erythema multiforme.

Clinical response to levamisole in thirty-nine patients with erythema multiforme. An open prospective study

Patients with erythema multiforme (EM) often have chronic or recurring oral lesions that cause intense pain and interfere with a variety of functions including eating and speech. Previous studies suggest that levamisole restores to normal the function of phagocytes and T lymphocytes, and activates the inflammatory response. In our previous double-blind study 8 of 13 patients with EM had a decrease in severity and frequency of attacks. The purpose of this open prospective study was to evaluate short-term and long-term clinical efficacy of levamisole in patients with mucocutaneous EM. Thirty-nine patients with mucocutaneous EM seen in the Oral Medicine Clinic, School of Dentistry, University of California-San Francisco, comprised our study group. Levamisole was used alone in 17 patients or in combination with prednisone in 22 patients and was given as a single dose of 150 mg/day for 3 consecutive days. Thirty-one patients showed a complete response from levamisole (alone in 13 and in combination with prednisone in 18). Four showed a partial response of signs and symptoms, and four others had no benefits from levamisole whether alone or in combination. The most common side effects from levamisole were skin rash, tiredness, weakness, myalgia, taste change, and insomnia.

Erythema multiforme: a literature review and case report

Erythema multiforme is a florid mucocutaneous disease characterized by oral, cutaneous, and ocular manifestations. The cutaneous lesions are pathognomonic because of their unique "target-like" appearance. A severe form of EM has been termed "Stevens-Johnson Syndrome". Although the etiology of EM is unknown, much of the research suggests an immunological association with HSV. The diagnosis of EM is based on signs and symptoms, and a differential diagnosis should include other ulcerative, mucocutaneous diseases, such as erosive lichen planus, pemphigus, varicella zoster, ANUG, TEN, aphthous stomatitis, and primary HSV. Therapeutic measures are palliative, including a soft bland diet, topical anesthetics, and corticosteroids. A case of EM is described which underscores the appearance of the disease and its clinical course.

Open preliminary clinical trial of clobetasol propionate ointment in adhesive paste for treatment of chronic oral vesiculoerosive diseases

Clobetasol propionate (Temovate), a novel high-potency topical corticosteroid, was used in open trial from 1987 to 1988 on 24 patients with persistent oral vesiculoerosive disease of at least 1 month's duration. Fourteen women and 10 men, ranging in age from 27 to 76 years (mean 48 years), participated. Nine patients had erosive lichen planus, one had benign mucous membrane pemphigoid, three had pemphigus vulgaris, seven had persistent major recurrent aphthous stomatitis, and four had chronic oral erythema multiforme. Fifteen patients had complete remission of signs and symptoms, seven had excellent response of signs and complete remission of symptoms, and two failed to respond. All other topical therapy was suspended before and during the study. All patients responded to two or three applications daily of medication. Side effects were minor and reversible, and included localized candidiasis (three patients), stomatopyrosis (two), and hypogeusia (one). Clobetasol propionate ointment in adhesive paste (Orabase) thus seems to be an effective topical steroid alternative to other less potent topical and systemic drugs for recalcitrant oral vesiculoerosive disease.

Multiple oral and skin lesions occurring after treatment with penicillin

A case of erythema multiforme has been presented. Erythema multiforme may be a self-limiting or chronic disease, of varying severity. The disease is of significance to dental practitioners who may be called on to establish a diagnosis and provide appropriate referral or treatment, especially when lesions are limited to the mouth. The prognosis is generally good, although recurrence is common.

Clinical features and management of severe dermatological reactions to drugs

Cutaneous adverse drug reactions are a frequent occurrence and have been reported in more than 2% of hospitalised patients. Among the most commonly involved drugs are sulphonamides, penicillins, anticonvulsants and non-steroidal anti-inflammatory drugs. Two groups of mechanisms are involved in the pathogenesis of drug reactions: immunological, with all 4 types of hypersensitivity reactions described; and non-immunological, accounting for at least 75% of all drug reactions. Besides minor skin reactions like urticaria, maculopapular rash, fixed eruptions or erythema nodosum, which are generally self-limited, severe life-threatening manifestations also occur. Erythema multiforme is secondary to drugs in half the cases; the minor form is characterised by typical target and iris lesions and is usually benign. However, a much more severe condition, erythema multiforme major or Stevens-Johnson syndrome, is associated with mucosal, ocular and visceral involvement, and carries a mortality of 5 to 15% if untreated. Toxic epidermal necrolysis, which could represent an even more dramatic form of the same disease, is characterised by severe widespread erythema, blisters and loss of skin in sheets, with denudation of more than 10% of the body surface area. This entity is frequently due to drugs. Mortality is 25 to 70%, and 90% of the survivors will have sequelae. Exfoliative dermatitis is an erythematous scaling disease often produced by drugs and carrying significant mortality. Photodermatitis may at times present with severe eczematous features. For clinical and epidemiological reasons it is important to try to identify the culprit drug following an approach based on previous experience with the drug, timing of events, patient reaction to dechallenge, patient reaction to rechallenge (if feasible), alternative aetiological candidates, and drug concentration or evidence of overdose. Management of severe skin reactions to drugs should require admission to a burn unit, where patients should be placed in warmed air-fluidised beds, receive excellent nursing care, analgesics and tranquillisers. Peeling necrotic epidermis should be removed and denuded dermis covered with biological grafts or synthetic dressings. Fluid balance must be adequately maintained; nutritional support and careful monitoring of early signs of skin infections is mandatory to ensure immediate antimicrobial treatment. Ocular care must be excellent to avoid serious sight-threatening sequelae. Steroids are presently not recommended. With these therapeutic modalities, morbidity and mortality can be markedly decreased.