Erythema is redness of the skin caused by increased blood flow to the capillaries. There are many causes and manifestations of erythema, including photosensitivity, erythema multiforme, and erythema nodusum. Photosensitivity refers to a skin reaction in response to the sun; it tends to occur when something, such as an infection or a medication, increases a person's sensitivity to ultraviolet radiation. Erythema multiforme is characterized by spots, blisters, or other lesions on the skin and usually results from a reaction to medications, infections, or illness. Erythema nodosum is a form of erythema that is accompanied by nodules, small round masses, typically on the arms and legs.
What Causes It?In half of all cases of either erythema multiforme or erythema nodosum, the exact cause is not identified. The following are examples of what may precipitate these skin reactions.
- Infection—primarily herpes simplex virus (HSV) and pneumonia caused by a particular type of organism called mycoplasma; influenza A and Epstein–Barr virus (the organism that causes mononucleosis) may also lead to erythema multiforme
- Medications—penicillin and other antibiotics such as a class containing sulfa; anticonvulsant medications; 5-fluorouracil used for certain forms of cancer
- Radiation therapy
- Infections—including tuberculosis and HSV
- Connective tissue disorders such as lupus
- Ulcerative colitis
- Medications—oral contraceptives; a class of antibiotics containing sulfa
Who's Most At Risk?
- Men are at greater risk than women for erythema multiforme.
- Women, on the other hand, are at greater risk for erythema nodosum.
- Excessive sun exposure increases the risk for erythema multiforme.
- Individuals with a family history of skin conditions have a greater chance of developing either erythema multiforme or erythema nodosum.
Signs and SymptomsErythema multiforme:
- Malaise, fever, itching of skin (before lesions appear)
- Sudden outbreak of spots, bumps, and lesions (typically on knees, elbows, palms, hands, feet, and mouth; trunk in severe cases)
- Target lesions (central lesion surrounded by concentric rings of normal and red skin)
- Erythema infectiosum (caused by a virus and known as fifth disease)—facial rash and rash on arms lasting about two weeks
- Malaise, fatigue, flu-like symptoms (before lesions appear)
- Clustures of nodules (small round masses) and lesions on shins, forearms, thighs, and trunk
- Red, hard, painful lesions become soft and bluish, and fade to yellow and brown
- Joint pain
What to Expect at Your Provider's OfficeHealthcare providers will perform a physical exam and may use procedures such as a skin biopsy, throat culture, blood test, or X ray to determine the type of erythema. Not only will these procedures help identify the type of skin condition, they may also reveal any infections or medications that are contributing to the symptoms.
PreventionTreat any underlying diseases and avoid any known triggers (certain medications, for example); it is also important to avoid being outside in the sun when taking certain medications that contribute to photosensitivity.
Treatment PlanHealthcare providers will treat any underlying diseases, eliminate drugs that may contribute to symptoms, and take steps to control current symptoms. While mild cases may not require treatment, bed rest and medication may be necessary for more severe cases.
Drug TherapiesHealthcare providers may prescribe various medications in the appropriate clinical setting, including:
- Antihistamines for itching
- Antibiotics to treat particular infections
- Antiviral medications such as acyclovir and valacyclovir
- Burrow's compresses—a solution used to soothe skin conditions, particularly blisters
- Immune-suppressing drugs, such as azathioprine, have shown mixed results
- Intravenous immunoglobulin has been used experimentally for SJS and TEN
- Steroids—topical for particular skin lesions; oral prednisone to reduce symptoms of erythema nodosum and to prevent recurrence of erythema multiforme, although this use is controversial
Complementary and Alternative TherapiesIn order to heal any type of erythema, the underlying cause of the skin condition must be treated. Certain complementary and alternative therapies, though, help to:
- Reduce inflammation
- Boost the immune system
- Prevent infections
Antioxidants found in some dietary supplements and topical preparations such as gels, ointments, or lotions may protect against skin damage caused by ultraviolet (UV) sun rays when used prior to exposure. Antioxidants are molecules that scavenge free radicals (highly active molecules that can injure cells and contribute to disease, including skin damage).
The following substances with antioxidant activity were found in studies to have benefit in protecting the skin in the circumstances described:
- Carotenoids appear to be effective at preventing skin damage when taken orally with or without vitamin E prior to sun exposure. Carotenoids can be found in fruits and vegetables as well as supplement form; beta-carotene is one common type.
- Flavonoids, such as quercetin, may help reduce the likelihood of developing erythema because they prevent inflammation and strengthen connective tissue; this, however, is only a theoretical benefit that has not been studied scientifically.
- Melatonin appears to have a protective effect when used topically in a gel, lotion, or ointment, either alone or in combination with topical vitamin E prior to exposure to UV radiation from the sun
- Vitamin C seems to be protective against developing erythema when used prior to sun exposure in either topical or oral form, although only when used in combination with topical or oral vitamin E
- Vitamin E seems to be protective when used prior to sun exposure in combination with either vitamin C or melatonin
- Zinc was used in a study as adjunctive treatment for a severe form of erythema multiforme similar to TEN; five out of eight people treated with zinc in addition to standard medical treatment had added benefit from this oral supplement
- Green tea (Camellia sinensis) may also protect against erythema caused by UV light because it contains antioxidants, like the micronutrients described in the section entitled Nutrition; this protection, when taken prior to exposure to UV radiation, has been suggested by animal studies as well as a recent preliminary human study.
- Burdock root (Arctium lappa) has been used topically for skin inflammation and wound healing
- Calendula (Calendula officinalis) has been used topically for burns, wounds, and other skin conditions; may be used as homeopathic remedy for these purposes as well
- Goldenseal (Hydrastis canadensis) has been used for infections, including those causing skin lesions
- Lemon balm (Melissa officinalis) can be applied to HSV lesions in the form of a cream or a wash
- Licorice root (Glycyrrhiza glabra) has been used topically for viruses and connective tissue disorders; should not be used orally in the case of high blood pressure
- Meadowsweet (Filipendula ulmaria) has been used for painful joints (as may be seen with erythema nodosum)
- Milk thistle (Silybum marianum) for chemical causes of skin lesions
- Slippery elm (Ulmus fulva) in combination with goldenseal root has been applied topically for treatment of open wounds
- Yarrow (Achillea millefolium) has been applied topically for skin inflammation and wound healing.
Animal studies suggest that homeopathic treatment with Apis may protect the skin against the damaging effects of radiation. Although few other studies have examined the effectiveness of specific homeopathic remedies in the treatment of erythema, professional homeopaths may recommend the following treatments based on their knowledge and clinical experience. Before prescribing a remedy, homeopaths take into account a person's constitutional type. In homeopathic terms, a person's constitution is his or her physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a particular individual.
- Apis mellifica —for skin rashes that feel hot and dry and are sensitive to touch; may be accompanied by sore throat; symptoms are relieved by cool drinks and baths and worsened by heat and warm liquids; this remedy is most appropriate for individuals who often feel sad, disappointed, or even depressed; they tend to cry easily but may also be irritable and envious by nature; they're also distinctly not thirsty but may crave milk
- Calendula – for burns and skin lesions that are fairly superficial; often used after the acute phase of the skin condition has subsided to aid in complete recovery
- Rhus toxicodendron — used for blisters and vesicles accompanied by intense itching that worsens at night and improves with the application of heat; this remedy is most appropriate for individuals who are generally restless and unable to get comfortable at night
- Sulphur —for skin disorders that are accompanied by fever and intense itching; this remedy is most appropriate for individuals who are thirsty, irritable while sick, lazy and messy under ordinary circumstances, and who describe a sensation of internal heat and burning; symptoms tend to improve with open, cold air and worsen with warmth
Massage should be avoided in cases of erythema because it may make any inflammation worse.
Prognosis/Possible ComplicationsWhen treated properly, signs and symptoms of erythema multiforme usually disappear in four to six weeks; symptoms of erythema nodosum, however, may reappear for up to two years. Symptoms of SJS typically disappear in a month, but when the condition is not treated properly it may lead to blindness. Ten percent may die from more severe forms of SJS. Up to 40 percent of those with TEN may die of the condition. If the drug causing either SJS or TEN is identified and discontinued quickly, a person's chance of survival significantly improves.
Following UpHealthcare providers will monitor fluid and electrolyte levels, protein loss, and any organ damage. Persons with erythema multiforme may need treatment in a hospital burn unit if 20% or more of their body is affected.
Special ConsiderationsErythema raises special issues related to pregnancy. If a pregnant woman develops erythema infectiosum (fifth disease), the virus can infect the fetus and cause fetal anemia, heart failure, hydrops (collection of watery fluid), and even death. Studies have also shown that pregnancy may trigger erythema nodosum. Finally, certain medications must be avoided during pregnancy; your healthcare provider will be able to direct your care appropriately.
Acyclovir. NMIHI. Accessed at http://www.nmihi.com/a/acyclovir.html on September 12, 2018.
Antihistamines. NMIHI. Accessed at http://drugs.nmihi.com/antihistamines.htm on September 12, 2018.
Amoxicillin. NMIHI. Accessed at http://www.nmihi.com/a/amoxicillin.html on September 12, 2018.
Azithromycin. NMIHI. Accessed at http://www.nmihi.com/a/azithromycin.html on June 19, 2018.
Beers MH, Berkow R, eds. The Merck Manual of Diagnosis and Therapy. 17th ed. Whitehouse Station, NJ: Merck Research Laboratories; 1999.
Blumenthal M, Goldberg A, Brinckmann J, eds. Herbal Medicine: Expanded Commission E Monographs. Newton, Mass: Integrative Medicine Communications; 2000:230-239, 253-263, 419-423.
Cummings S, Ullman D. Everybody's Guide to Homeopathic Medicines. 3rd ed. New York, NY: Penguin Putnam; 1997: 227, 319-320, 345-346.
Dambro MR. Griffith's 5 Minute Clinical Consult. Baltimore, Md: Lippincott Williams & Wilkins, Inc.; 1999.
Dreher F, Denig N, Gabard B, Schwindt DA, Maibach HI. Effect of topical antioxidants on UV-induced erythema formation when administered after exposure. Dermatology. 1999;198(1):52-55.
Dreher F, Gabard B, Schwindt DA, Maibach HI. Topical melatonin in combination with vitamins E and C protects skin from ultraviolet-induced erythema: a human study in vivo. Br J Dermatol. 1998;139(2):332-339.
Eberlein-König B, Placzek M, Przybilla B. Protective effect against sunburn of combined systemic ascorbic acid (vitamin C) and d-alpha-tocopherol. J Am Acad Dermatol. 1998;38(1):45-48.
Erythema. NMIHI. Accessed at http://www.nmihi.com/e/erythema-multiforme.htm on September 12, 2018.
Erythema multiforme. MedlinePlus. Accessed at https://medlineplus.gov/ on June 19, 2018.
Fauci AS, Braunwald E, Isselbacher KJ, et al., eds. Harrison's Principles of Internal Medicine. 14th ed. New York, NY: McGraw-Hill; 1998.
Fuchs J, Kern H. Modulation of UV-light-induced skin inflammation by D-alpha-tocopherol and L-ascorbic acid: a clinical study using solar simulated radiation. Free Radic Biol Med. 1998;25(9):1006-1012.
Garcia-Doval I, LeCleach L, Bocquet H, Otero XL, Roujeau JC. Toxic epidermal necrolysis and Stevens-Johnson syndrome: does early withdrawal of causative drugs decrease the risk of death? Arch Dermatol. 2000;136(3):323-327.
Garcia-Porrua C, Gonzalez-Gay MA, Vazquez-Caruncho M, et al. Erythema nodosum: etiologic and predictive factors in a defined population. Arthritis Rheum. 2000;43(3):584-592.
Habif TP. Clinical Dermatology. 3rd ed. St. Louis, Mo: Mosby-Year Book; 1996.
Halliday GM, Yuen KS, Bestak R, Barnetson RS. Sunscreens and vitamin E provide some protection to the skin immune system from solar-simulated UV radiation. Australas J Dermatol. 1998;39(2):71-75.
Jonas WB, Jacobs J. Healing with Homeopathy: The Doctors' Guide. New York, NY: Warner Books; 1996: 263-265.
Is It Just a Rash? Dr. Axe. Accessed at https://draxe.com/ on June 19, 2018.
Katiyar SK, Matsui MS, Elmets CA, Mukhtar H. Polyphenolic antioxidant (-)-epigallocatechin-3-gallate from green tea reduces UVB-induced inflammatory responses and infiltration of leukocytes in human skin. Photochem Photobiol. 1999;69(2):148-153.
Khanna VJ, Shieh S, Benjamin J, et al. Necrolytic acral erythema associated with hepatitis C: effective treatment with interferon alfa and zinc. Arch Dermatol. 2000;136(6):755-757.
Lee J, Jiang S, Levine N, Watson RR. Carotenoid supplementation reduces erythema in human skin after simulated solar radiation exposure. Proc Soc Exp Biol Med. 2000;223(2):170-174.
Lo SK, Yip D, Leslie M, Harper P. 5-flourouracil-induced erythema multiforme. Int J Clin Pract. 1999;53(3):219-221.
Mandell GL, Bennett JE, Dolin R, eds. Principles and Practices of Infectious Diseases. 5th ed. Philadelphia, Pa: Churchill Livingstone, Inc.; 2000.
Martinez AE, Atherton DJ. High-dose systemic corticosteroids can arrest recurrences of severe mucocutaneous erythema multiforme. Pediatr Dermatol. 2000;17(2):87-90.
Minocycline. NMIHI. Accessed at http://www.nmihi.com/m/minocycline.html on September 12, 2018.
Murray M. Encyclopedia of Nutritional Supplements. Rocklin, Calif: Prima Publishing; 1996:320-335.
Rakel RE, ed. Conn's Current Therapy. 51st ed. Philadelphia, Pa: W.B. Saunders; 1999.
Sinclair SA, Reynolds NJ. Necrolytic migratory erythema and zinc deficiency. Br J Dermatol. 1997;136(5):783-785.
Stahl W, Heinrich U, Jungmann H, Sies H, Tronnier H. Carotenoids and carotenoids plus vitamin E protect against ultraviolet light-induced erythema in humans. Am J Clin Nutr. 2000;71(3):795-798.
Stern RS. Improving the outcome of patients with toxic epidermal necrolysis and Stevens-Johnson syndrome. Arch Dermatol. 2000;136(3):410-411.
Symptoms of erythema multiforme. NHS. Accessed at https://www.nhs.uk/ on June 19, 2018.
Vickers AJ. Independent replication of pre-clinical research in homoeopathy: a systematic review. Forsch Komplementarmed. 1999;6(6):311-320.
What Is Erythema Multiforme? The Nemours Foundation. Accessed at https://kidshealth.org/ on June 19, 2018.