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
Infections—including tuberculosis and
Connective tissue disorders such as lupus
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
Individuals with a family history of skin conditions have a greater
chance of developing either erythema multiforme or erythema nodosum.
Signs and Symptoms
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
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
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), perhaps
the most severe forms of erythema multiforme, are characterized by a different
set of symptoms. Target lesions on the trunk, hacking cough, fever, and blisters
around the mouth, eyes, nostrils, and anal and vaginal areas are the key
symptoms of SJS. A person with TEN will have symptoms of SJS that eventually
worsen to include peeling and detachment of the skin, pus-like infections, fluid
loss, and even death.
What to Expect at Your Provider's Office
Healthcare 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.
Treat 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.
Healthcare 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.
Healthcare 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
Intravenous immunoglobulin has been used experimentally for SJS and
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
Complementary and Alternative Therapies
In 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:
Boost the immune system
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
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
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
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.
Herbs traditionally used to heal damaged skin, promote lymph circulation, and
possibly treat the underlying cause of various skin conditions may be helpful.
Although these have not been tested scientifically for erythema specifically,
some examples include:
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
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.
It is best and safest to see a trained, experienced herbalist for guidance
about the use of herbs to treat erythema.
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
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
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
Massage should be avoided in cases of erythema because it may make any
When 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
Healthcare 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.
Erythema 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.
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,
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.
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.
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
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.
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
Khanna VJ, Shieh S, Benjamin J, et al. Necrolytic acral erythema associated
with hepatitis C: effective treatment with interferon alfa and zinc. Arch
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.;
Martinez AE, Atherton DJ. High-dose systemic corticosteroids can arrest
recurrences of severe mucocutaneous erythema multiforme. Pediatr
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.
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.
Vickers AJ. Independent replication of pre-clinical research in homoeopathy:
a systematic review. Forsch Komplementarmed.
Review Date: December 2001
Reviewed By: Participants in the review process include: Robert A. Anderson, MD, President
, American Board of Holistic Medicine, East Wenatchee, WA; Constance Grauds,
RPh, President, Association of Natural Medicine Pharmacists, San Rafael, CA;
Jacqueline A. Hart, MD, Department of Internal Medicine, Newton-Wellesley
Hospital, Harvard University and Senior Medical Editor Integrative Medicine,
The publisher does not accept any responsibility for the accuracy of
the information or the consequences arising from the application, use, or misuse
of any of the information contained herein, including any injury and/or damage
to any person or property as a matter of product liability, negligence, or
otherwise. No warranty, expressed or implied, is made in regard to the contents
of this material. No claims or endorsements are made for any drugs or compounds
currently marketed or in investigative use. This material is not intended as a
guide to self-medication. The reader is advised to discuss the information
provided here with a doctor, pharmacist, nurse, or other authorized healthcare
practitioner and to check product information (including package inserts)
regarding dosage, precautions, warnings, interactions, and contraindications
before administering any drug, herb, or supplement discussed