GENERAL PRINCIPLES OF TREATMENT:

EM is caused by inflammation. The inflammation can be a result of another known triggering factor or unexplained. We aim to suppress the inflammation and ideally its cause when known.

• If the cause is an underlying illness/exposure (i.e., medication allergy, mycoplasma, histoplasma, orf), address the underlying condition.

• HSV associated EM typically responds to valacyclovir or famciclovir; however, it also may require trials of other therapies.

• Sometimes HSV associated EM as well as idiopathic EM may respond to initial therapies but then evolve to become resistant to an initial treatment.

The initial episode of EM (whether idiopathic or herpes associated) could be treated with prednisone and valacyclovir. Depending on the frequency and severity of subsequent flares, the following strategies might be considered:

• Mild flares of limited body surface area (BSA) can be managed with potent topical steroids such as clobetasol.                      

• Limited oral involvement can be managed with triamcinolone in Orabase.

• Flares that occur infrequently, less than 4 times per year, can be managed with repeated short prednisone tapers akin to the initial bout.

• For more severe and frequent flares, a steroid sparing approach should be employed. On a case by case basis, one chooses an agent based upon:

  • Likelihood to induce remission

  • Safety profile

• For very severe cases, consider employing prednisone or cyclosporine. For patients with less risk tolerance, choose the agent with as much potential efficacy as possible while aligning with the patient’s risk tolerance.

• Treatment options are discussed under the "Treatments" tab in the contexts of:

  • Most likely to induce remission (with dosing and safety discussion)

  • Topical options

  • Less reliable anecdotal options

Disclaimer: risks represent the major considerations but are not all-inclusive.

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