Erythema Multiforme or Urticaria Vasculitis? Different paths lead to the same destination 殊途同归
A 30-year-old woman found her world turned upside down two months ago when she developed a distressing skin condition. Initially, she experienced itchiness and raised bumps on her neck, which her family doctor diagnosed as Urticaria and prescribed her with a steroid (dexamethasone) cream as treatment. However, the rash persisted and resurfaced four weeks later, thus introducing to a course of oral steroids (prednisolene) 7 days and antihistamines. Sadly, these conventional treatments proved ineffective, leaving her disheartened. Determined to find a solution, she turned to alternative therapies here at our TCM dermatolgoy clinic.
Upon examination, multiple target-like papules are symmetrically distributed on her arms and legs (Fig.1). Its colour varied from pink to dark to violaceous, accompanied by mild itchiness. She has no family history of similar conditions or recent illnesses, but she had been diligently taking fish oil supplements in the past 6 months. Based on these findings, a provisional diagnosis of either Erythema Multiforme or Erythema Annulare was made. We prescribed personalized herbal Traditional Chinese Medicine (TCM) Tangs Vitigo and Tangs Psoria , ceased the use of steroids and fish oil, and continued the antihistamines along with our herbal yufu cream.
The initial response to the withdrawal of steroids was unfavorable, as her rashes worsened and the lesions on her skin enlarged, accompanied by severe itchiness. Overwhelmed with panic, she sought assistance from the dermatology department at a hospital, where she received a diagnosis of Erythema Multiforme. The doctors prescribed a 10-day course of oral steroids (prednisolone), gradually tapered down, along with topical steroids cream (momethasone furoate) and urea cream. Additionally, she was advised to continue taking antihistamines (fexofenadine) for an additional three weeks.
Despite these treatments, her condition took an unexpected turn. A few days after discontinuing the steroids, a sudden rash spread across her entire body, affecting her arms, legs, and thigh area. The rash presented itself as flakes and reddish lesions, accompanied by a burning and pruritic sensation. Alarmed, she sought urgent help at the Accident and Emergency (A&E) department. At the hospital, she received a new diagnosis of Urticaria Vasculitis and was prescribed a 21-day course of oral steroids (prednisolone) and continued taking antihistamines. However, this time, she decided not to take steroids and instead maintained her usual TCM herbal medication regimen.
As the days passed, her hope and confidence in TCM grew stronger. The herbal remedies seemed to work wondrously with her body, providing relief when conventional medicines had failed. Gradually, from the fifth week of following the TCM treatment plan, she noticed a positive change in her condition. The skin lesions began to fade, and the itching and discomfort diminished.
Over the course of ten weeks, her skin condition significantly improved, and her radiant spirit returned. Her journey with erythema multiforme taught her the power of exploring alternative paths to healing. Through the wisdom of Traditional Chinese Medicine and its herbal remedies, she discovered a solution that worked for her when conventional medicine fell short.
Discussion
Urticaria (hives), Erythema Multiforme, Erythema Annulare, and Urticaria Vasculitis are immune system-mediated skin conditions. In conventional medicine, the standard approach for these conditions often involves the use of immunosuppressive medications. While topical and oral steroids can provide relief and induce a clinical remission, it is important to note that recurrences are common when steroids are discontinued or tapered off.
Erythema Multiforme (EM) is generally considered a self-limited disease, meaning that the episode lasts 2 weeks and heals without sequelae (1-5). However, it’s important to note that the duration and severity of EM can vary from person to person. While the majority of EM cases follow a self-limited course, there have been reports of chronic or recurrent forms of the condition. These cases, known as persistent, recurrent, or chronic erythema multiforme, are relatively rare but can pose challenges in terms of management and treatment.
Chronic erythema multiforme is characterized by recurrent episodes of EM lesions that persist for longer durations, sometimes extending beyond the typical time frame of a self-limited episode. These cases may require ongoing or intermittent treatment to control symptoms and prevent recurrences.
Reference:
- von Hebra F. On Diseases of the Skin, Including the Exanthemata. The New Sydenham Society: London; 1866.
- von Hebra F. Akute Exantheme und Hautkrankheiten. Verlag von Ferdinand von Enke: Erlangen; 1860:198–200.
- Brice SL, Huff JC, Weston WL. Erythema multiforme. Curr Probl Dermatol. 1990;II:3–26.
- Schofield JK, Tatnall FM, Leigh IM. Recurrent erythema multiforme: clinical features and treatment in a large series of patients. Br J Dermatol. 1993;128:542–545.
- Weston WL. What is erythema multiforme? Pediatr Ann. 1996;25:106–109.
Privacy
In situations where the disease information had already been made publicly available (as evidenced by prior articles), genuine names of individuals have been utilized. Conversely, in instances where there was no pre-existing public disclosure or at the explicit request of patients for privacy, pseudonyms have been employed. Furthermore, identities have been deliberately obscured, and certain contextual details and diagnoses have been modified to hinder any attempts at identification. It is essential to emphasize that the patients and encounters described in this work are authentic, and their consent for publication was duly obtained. As responsible authors, we earnestly implore all our readers to honor the privacy and confidentiality of these individuals. Additionally, certain scenarios, assessments, and clinical interventions have been altered to safeguard the anonymity of both patients and healthcare providers.
