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BET 2. STEROIDS IN CHILDREN WITH ERYTHEMA MULTIFORME
  1. Mark Riley, ST3 in Emergency Medicine,
  2. Rachel Jenner, Consultant in Emergency Medicine
  1. Booth Hall Children’s Hospital, Manchester, Manchester, UK

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    Report by Mark Riley, ST3 in Emergency Medicine

    Search checked by Rachel Jenner, Consultant in Emergency Medicine

    Institution: Booth Hall Children’s Hospital, Manchester, Manchester, UK

    A short-cut review was carried out to establish whether steroids are of any benefit in children with erythema multiforme. From a search of 136 papers only two presented controlled evidence addressing the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The clinical bottom line is that early brief high-dose steroids may be of benefit in erythema multiforme major. Steroids are not recommended in erythema multiforme minor.

    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 that appears to be target lesions after a viral upper respiratory tract infection. 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 (0–18 years)”.

    SEARCH OUTCOME

    A total of 136 articles was 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 that 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.

    Table 1 Relevant papers

    COMMENTS

    No large multicentre, randomised, blinded controlled trial comparing steroids with placebo in children with erythema multiforme major or minor has been performed.

    The small prospective randomised controlled trial 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 (ie, Stevens–Johnson syndrome/toxic epidermal necrosis), with a reduction in the 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 a 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.

    References