Approach
EM is self-limiting, with management based on the following strategies:
Supportive care to maintain hydration and prevent erosions from developing secondary bacterial infection
Treatment of suspected precipitating infections
Withdrawal of suspected offending drugs
Suppression therapy with antivirals if recurrent disease is caused by herpes simplex virus (HSV)
Topical or systemic corticosteroids to reduce inflammation.
Evidence for treatment of EM is limited, with most recommendations based on small retrospective case series or expert opinion.[41][45]
Supportive care
EM minor (typical targets or raised oedematous papules, with acral distribution, without involvement of mucosal sites, and involving <10% total body surface area)
Lesions should be cleaned twice daily with soap and water. Topical emollients should be applied to all lesions to hydrate the skin and also act as a protective barrier. If any lesions are open, they should be cleaned gently and covered with sterile dressings to prevent secondary bacterial infection.
Analgesics (e.g., paracetamol, non-steroidal anti-inflammatory drugs [NSAIDs]) can be taken for general pain and discomfort caused by the lesions.
EM major (typical targets or raised oedematous papules, with acral distribution, plus involvement of 1 or more mucosal sites, and involving <10% total body surface area)
Topical emollients, gentle cleaning, and sterile covers over open lesions may aid in prevention of bacterial superinfection of blistered and eroded lesions.
For painful oral lesions, a topical lidocaine solution can be applied directly onto the lesions and a mouthwash used to coat and soothe prior to intake of liquids and foods.
Although few patients are ill enough to require hospitalisation, and disease generally remits without specific therapy, some patients with EM major may require intravenous fluids if they become volume depleted from poor oral intake.
If urethra is blocked due to sloughing of the mucosa, catheterisation may help in voiding.
Oral analgesics may reduce lesional discomfort.
Treatment of precipitating infections
Herpes simplex virus
Oral antivirals are used for cases of oral HSV (cold sores) and genital herpes. See Herpes simplex virus infection (Management approach).
Mycoplasmal pneumonia
Guidelines on the treatment of atypical pneumonia recommend empirical use of a macrolide or doxycycline for uncomplicated community-acquired pneumonia to ensure coverage of atypical organisms.[46] See Mycoplasma pneumoniae infection (Management approach).
Treatment of inflammation
Topical or systemic corticosteroids can be used to reduce inflammation. In EM minor, topical corticosteroids have been shown to benefit clearance of lesions.[1][2][36] Oral prednisone may also be used. For EM major, oral or intravenous corticosteroids may be required.
Prevention of recurrences
If recurrent HSV infection is found to be the cause for repeated episodes of EM, suppressive therapy using antivirals can be started.[45] Careful initiation of a daily or twice-daily dose of valaciclovir for 1 day can be used at the first sign of an oral HSV outbreak. If this does not control symptoms, a daily dose of valaciclovir for at least 6 months can be given. The dose may need to be doubled in order to bring symptoms under control.[41] Aciclovir is preferred for those patients who need liquid formulations.
Patients can be advised to avoid environmental triggers of oral herpes recurrences, such as sun exposure.
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