Recurrent bullous erythema multiforme treated with topical tacrolimus 0·1% ointment

Abstract

Funding sources: none. Conflicts of interest: none declared. Madam, Recurrent erythema multiforme, defined as ‘the presence of a symmetrically distributed, fixed eruption, including target lesions, with or without mucous membrane involvement, occurring on at least three occasions’, is a condition of substantial morbidity.1 Herpes simplex virus (HSV) has been implicated as a causative factor in recurrent erythema multiforme.2 Continuous antiviral therapy has been used to suppress recurrent erythema multiforme.3 Immunosuppressive agents are typically used for patients who do not respond to antiviral therapy, often with varied and suboptimal response.4 We report a 56‐year‐old woman with recurrent bullous erythema multiforme, which responded to treatment with topical tacrolimus 0·1% ointment. This patient presented to her family doctor in April 2007 with targetoid plaques and bullae affecting her forearms and chest. This was preceded by an episode of herpes labialis. She was treated with oral prednisolone 20 mg daily and the rash resolved over 3 weeks. She presented to our department 1 year later with target lesions consisting of plaques and bullae affecting her forearms and hands (Fig. 1a, b), knees and feet, and with three red macules on the hard palate. A skin biopsy from the palmar left hand confirmed the diagnosis of bullous erythema multiforme, with bulla formation along the dermoepidermal junction with confluent necrosis of the epidermis. Direct immunofluorescence demonstrated a granular deposition of complement C3 along the basement membrane (Fig. 2a, b). The diagnosis was bullous erythema multiforme secondary to HSV infection and she was commenced on valaciclovir 500 mg once daily. Subsequently she developed further episodes of bullous erythema multiforme at the same site, without evidence of herpes simplex infection and some were painful and unsightly, particularly on her hands. She was using topical clobetasol propionate 0·05% ointment daily, using approximately 30 g weekly, but this failed to control her disease and she had weekly flares. Topical tacrolimus 0·1% ointment once daily was commenced, which resulted in resolution of existing lesions over 1 month, and allowed discontinuation of topical steroids. Topical tacrolimus 0·1% has effectively suppressed the appearance of any new lesions over the last 4 months.