Herpes-associated erythema multiforme in a postmenopausal woman


Hendri Susanto(1*), Nurhilailah Nurhilailah(2), Raziv Ganesha(3), Hening Tuti Hendarti(4), Priyo Hadi(5)

(1) Department of Oral Medicine, Faculty of Dentistry, Universitas Gadjah Mada, Yogyakarta
(2) Dental Study Program, Faculty of Dental Medicine, Universitas Airlangga, Surabaya, East Java
(3) Oral Medicine Specialist Program, Department of Oral Medicine, Faculty of Dental Medicine, Universitas Airlangga, Surabaya, East Java
(4) Department of Oral Medicine, Faculty of Dental Medicine, Universitas Airlangga, Surabaya, East Java
(5) Department of Oral Medicine, Faculty of Dental Medicine, Universitas Airlangga, Surabaya, East Java
(*) Corresponding Author


Herpes-associated erythema multiforme (HAEM) is an acute inflammatory mucocutaneous disease which is characterized by ulcerative lesion on oral mucous membrane with or without skin involvements. The etiology of erythema multiforme (EM) is probably hypersensitivity reaction to human herpes simplex virus tipe 1 (HSV-1). Lesions on lips with HAEM can be treated by corticosteroid and acyclovir topically and/or orally. The objective of this study was
to report the case of HAEM with painful ulcers accompanying with crust on lips. A 55 years old woman complained painful ulcers with crust on lips since the last five months. She had visited a primary health care service and received several medications such as antibiotic (ciprofloxacin), anti-inflammatory drug (corticosteroid), analgesic (mefenamic acid) but her complaint was never healed completely because it was always recurring. The lesion on her lips got worse when she ate hot and spicy food and after she went out for outdor activities. She had a history of herpes virus infection seven months before but it was completely healed after treated by acyclovir topically and amoxicilin orally. An extra oral examination found black brown crust on her upper lip vermillion, well-demarcated, irregular margin, rough surface, erythematous surrounding area, accompanied with pain. An intra oral examination identified ulcers, yellowish, 4-5 mm in size, well-demarcated, irregular margin, redness in surronding area, accompanied with pain. A
complete blood count examination, serology test for HSV-1 (IgM and IgG) were taken and the result showed that only IgG was reactive. The therapies given to the patient were topical medications with a combination of corticosteroid, chloramphenicol and moisturizer, followed by methyl prednisolone and acyclovir orally. After 6-week treatment, the lesions were completely healed.Herpes-associated erythema multiforme (HAEM) caused by hypersensitivity reaction
to herpes simplex virus type 1 (HSV-1) may have a characteristic of painful ulcers accompanied with crust on the lips. The combination of both anti-inflammatory and antiviral drugs can be a choice for the therapy.


crust; herpes-associated erythema multiforme (HAEM); herpes simplex virus type 1 (HSV-1); lip ulcer

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1. Glick M. Burket’s Oral Medicine. 12th ed. (Glick M, ed.). Shelton, Connecticut: People’sMedical
Publishing House; 2015. 69-71.

2. Ayangco L, Rogers RS. Oral manifestations of erythema multiforme. Dermatol Clin. 2003; 21(1): 195–205. doi: 10.1016/s0733-8635(02)00062-1

3. Farthing P, Bagan J, Scully C. Erythema Multiforme. Oral Dis. 2005; 11(5): 261–267.
doi: 10.1111/j.1601-0825.2005.01141.x

4. Lamoreux MR, Sternbach MR, Hsu WT. Erythema Multiforme. Am Fam Physician 2006; 74: 1883–1888.

5. Weston WL, Morelli JG. Herpes simplex virusassociated erythema multiforme in prepubertal
children. Arch Pediatr Adolesc Med. 1997; 151(10): 10114–1016. doi: 10.1001/archpedi.1997.02170470048009

6. Chen Y-C, Chang C-H. Herpes simplex virus-associated recurrent erythema multiforme: the implication of mhc class molecules on susceptibility. Dermatol Sin. 2008; 26(3): 165–170. doi: 10.29784/DS.200809.0006

7. Sharma A, Singh HP, Kaur P, Gupta I. Management of erythema multiforme secondary
to herpes simplex by systemic corticosteroid: a case report. Journal of Dental Sciences. 2013;
1(3): 45–49.

8. Davis K, Smith C, Halpern L, Esuruoso O, Ballard B. Erythema multiforme associated
with herpes simplex virus: a case report and literature review. J Dent & Oral Disord. 2016;
2(5): 1027–1025.

9. Alfar MY, Alrousan M, Almajali Z, Batarseh E, Alsaddi R. The use of corticosteroids in
management of herpes associated erythema multiforme. J Pak Med Assoc. 2015; 65(12):

10. Osterne RLV, Brito RGdM, Pacheco IA, Alves APNN, Sousa FB. Management of erythema
multiforme associated with recurrent herpes infection: a case report. J Can Dent Assoc.
2009; 75(8): 597–601.

11. Kishore M, Panat SR, Aggarwal A, Upadhyay N, Agarwal N. Herpes associated
erythema multiforme-a diagnostic dilemma. International Journal of Scientific Study.
2013; 01(02): 82–86.

12. Choudhari S, Chaudhary M, Gadbail A, Sharma A, Tekade S. Oxidative and antioxidative
mechanisms in oral cancer and precancer : a review. Oral Oncol. 2014; 50(1): 10–18.
doi: 10.1016/j.oraloncology.2013.09.011

13. Kamala K, Ashok L, Annigeri R. Herpes associated erythema multiforme. Contemp
Clin Dent. 2011; 2(4): 372-375. doi: 10.4103/0976-237X.91807

14. Page J, Taylor J, Tideman RL, Seifert C, Marks C, Cunningham A, Mindel A. Is HSV serology
useful for the management of first episode genital herpes? Sex Transm Infect. 2003; 79(4): 276–279. doi: 10.1136/sti.79.4.276

15. Legoff J, Péré H, Bélec L. Diagnosis of genital herpes simplex virus infection in the clinical
laboratory. Virol J. 2014; 11: 83. doi: 10.1186/1743-422X-11-83

16. Wood NH, Khammissa R, Meyerov R, Lemmer J, Feller L. Actinic cheilitis: a case report and a
review of the literature. Eur J Dent. 2011; 5(1): 101–106.

17. Maria A, Miranda DO, Ferrari TDM, Leite TC, Cunha KSG, Dias EP. Actinic cheilitis: clinical characteristics observed in 75 patients and a summary of the literature of this often neglected premalignant disorder. International Journal of Clinical Medicine. 2014; 5(21): 1337–1344. doi: 10.4236/ijcm.2014.521171

18. Aurelian L, Burnett JW. Current understanding of herpes simplex virus-associated erythema
multiforme. Expert Review Dermatology. 2008; 3(4): 491–499. doi: 10.1586/17469872.3.4.491

19. Weston WL. Herpes associated erythema multiforme. J Invest Dermatol. 2005; 124(6):
xv–xvi. doi: 10.1111/j.0022-202X.2005.23764.x

20. Issrani R, Prabhu N. Etiopathogenesis of erythema multiforme - a concise review.
Advances in Dentistry & Oral Health. 2017; 5(4): 5555669. doi: 10.19080/ADOH.2017.05.5555669

21. Duman T, Aktas G, Atak B, Kocak MZ, Erkus E, Savli H. A case of erythema multiforme with
unknown etiology. Clin Med Reports. 2018; 1(2): 1–2. doi: 10.15761/CMR.1000110

22. Kwatra G, Mukhopadhyay S. Topical corticosteroid : pharmacology. In: A Treatise
on Topical Corticosteroids in Dermatology: Use, Misuse and Abuse. 2017. 1–333.

23. Jasiecka A, Mas̈lanka T, Jaroszewski JJ. Pharmacological characteristics of metamizole.
Pol. J. Vet. Sci. 2014; 17(1): 207–214. doi: 10.2478/pjvs-2014-0030

24. Ashton H. Guidelines for the rational use of benzodiazepines. When and what to use. Drugs 1994; 48(1): 25–40. doi: 10.2165/00003495-199448010-00004

25. Guo S, DiPietro LA. Critical review in oral biology & medicine: Factors affecting wound healing. Journal of Dental Research. 2010; 89(3): 219–229. doi: 10.1177/0022034509359125

26. Ghosh A, Pallavi S, Nagpal B, Hegde U. Role of vitamins in oral health & disease : an overview. Indian Journal of Applied Research. 2015; 5(12): 292–295.

27. Goswami TK, Bhar R, Jadhav SE, Joardar SN, Ram GC. Role of dietary zinc as a nutritional
immunomodulator. Asian-Australasian Journal of Animal Sciences. 2005; 18(3): 439–452.
doi: 10.5713/ajas.2005.439

28. You Y, Wang L, Li Y, Wang Q, Cao S, Tu Y, Li S, Bai L, Lu J, Wei Z, Chen W, Hao F. Multicenter
randomized study of inosine pranobex versus acyclovir in the treatment of recurrent herpes
labialis and recurrent herpes genitalis in Chinese patients. J Dermatol. 2015; 42(6): 596–601. doi: 10.1111/1346-8138.12845

29. Madhavan HN, Bagyalakshmi R. Farewell, chloramphenicol ? is this true ?: a review.
Journal of Microbiology and Biotechnology. 2014; 3(1): 13–26.

30. Vries MD. The Fall and Rise of Universals on Relativization. Journal of Universal Laguage
6. 2005; 6: 125 - 157.

31. McCormack MG, Smith AJ, Akram AN, Jackson M, Robertson D, Edwards G. Staphylococcus
aureus and the oral cavity: an overlooked source of carriage and infection? Am J Infect
Control 2015; 43(1): 35–37. doi: 10.1016/j.ajic.2014.09.015

32. Mehta P. Acyclovir. Pediatr Infect Dis. 2013; 5: 178–180.

33. Jiang Y-C, Feng H, Lin Y-C, Guo X-R. New strategies against drug resistance to herpes
simplex virus. Int J Oral Sci. 2016; 8(1): 1–6. doi: 10.1038/ijos.2016.3

DOI: https://doi.org/10.22146/majkedgiind.43299

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