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Three Part Question

In [children with erythema multiforme] do [steroids] improve [outcome]

Clinical Scenario

You see an 8 year old girl who developed a widespread rash which appears to be target lesions after a viral URTI. You make a diagnosis of erythema multiforme. You wonder whether steroids may be of some benefit, but your consultant questions whether there is any evidence.

Search Strategy

Medline via Ovid interface 1950 to April week 1 2008
{exp Erythema Multiforme/or Erythema Multiform$.mp or exp Erythema Multiforme/or exp Epidermal Necrolysis, Toxic/or exp Stevens-Johnson Syndrome or Stevens-Johnson$.mp/ or (Steven$ adj Johnson$).mp} AND {exp Steroids/or Steroid$.mp or exp Prednisolone/ or prednisolone.mp or exp Hydrocortisone/or hydrocortisone.mp or exp Dexamethasone/or dexamethasone.mp or exp Methylprednisolone/or methylprednisolone.mp} limit to (humans and English language) and "all child (0-18years)".

Search Outcome

A total of 136 articles were found, 11 were related to the topic in question. All case reports, letters, and uncontrolled case series were excluded. There was one non-systematic review which did not add any other papers. One retrospective controlled case series and one prospective controlled trial were identified. These two studies were used to answer the three part question.

Comment(s)

No large multicentre, randomised, blinded controlled trial comparing steroids to placebo in children with erythema multiforme major or minor has been performed. The small PRCT performed by Kakourou et al. suggests that the early use of a short course of high dose steroids may be of some benefit to children with Erythema Multiforme Major (i.e. Stevens-Johnson Syndrome/ Toxic Epidermal Necrosis), with a reduction in duration of symptoms and only minor complications. The paper by Rasmussen suggests that longer courses of lower dose steroids lead to more complications and therefore prolonged time to recovery. There is no evidence for children with Erythema Multiforme Minor benefiting from steroids.

Clinical Bottom Line

Early, brief high dose steroids should be considered for children with Erythema Multiforme Major, but are not recommended for children with Erythema Multiforme Minor.