How to treat a patient with erythema multiforme (EM), liver cirrhosis, and an upper gastrointestinal (GI) bleed, who has a contraindication to steroid use?

Management of Erythema Multiforme in a Patient with Liver Cirrhosis and Active Upper GI Bleeding

In this complex scenario, you should prioritize supportive care with topical therapies for the erythema multiforme while aggressively managing the upper GI bleed according to standard cirrhosis protocols—systemic steroids are absolutely contraindicated given the active bleeding and cirrhosis. 1, 2

Immediate Priorities for the Upper GI Bleed

The upper GI bleeding takes precedence over the erythema multiforme as it poses the immediate mortality risk:

• Initiate vasoactive drug therapy immediately (terlipressin, somatostatin, or octreotide) even before endoscopic confirmation, continuing for 3-5 days after endoscopy 1, 3
• Start antibiotic prophylaxis immediately with ceftriaxone 1g IV daily (preferred in decompensated cirrhosis) for up to 7 days to reduce infection risk and improve survival 1, 3
• Maintain restrictive transfusion strategy with hemoglobin target of 7-9 g/dL to avoid increasing portal pressure 1, 3
• Perform upper endoscopy within 12 hours once hemodynamically stable, with endoscopic band ligation as the preferred therapy for esophageal varices 1, 3

Management of Erythema Multiforme WITHOUT Systemic Steroids

Since systemic corticosteroids are contraindicated due to:

1. Active GI bleeding (steroids impair hemostasis and increase rebleeding risk) 3
2. Infection risk in cirrhosis (antibiotics are already being given for bleeding prophylaxis) 1
3. Limited evidence that steroids benefit erythema multiforme minor 4

Use topical therapies exclusively for the erythema multiforme:

First-Line Topical Management

• Apply high-potency topical corticosteroids (triamcinolone, clobetasol) to affected skin areas, avoiding the face where low-potency hydrocortisone should be used 3, 5
• Use topical lidocaine (cream, ointment, or patches) for pain control on affected areas, particularly practical for extremities where patches can be worn for 12-24 hours 3
• Administer oral antihistamines for symptomatic relief of pruritus 3, 2

Mucosal Involvement Management

If mucosal lesions are present:

• Apply antiseptic or anesthetic solutions (lidocaine viscous solution) to oral lesions 5
• Maintain adequate hydration and electrolyte balance through IV fluids if oral intake is compromised 2, 1
• Monitor for secondary infections of mucosal lesions given the immunocompromised state from cirrhosis 5

Identify and Treat the Underlying Etiology

While managing both conditions acutely:

• Screen for herpes simplex virus (most common trigger) with viral cultures or PCR from lesions 2, 5
• Review all medications for potential drug triggers and discontinue any non-essential medications that could cause EM 2, 5
• Evaluate for Mycoplasma pneumoniae if respiratory symptoms are present 2

If HSV is identified as the trigger, defer antiviral prophylaxis until the GI bleeding is controlled and the patient is stable, as this is not immediately life-threatening 5

Critical Monitoring During Hospitalization

• Monitor for hepatic encephalopathy (common with GI bleeding in cirrhosis) and treat with lactulose if it develops 1, 3
• Assess EM lesion progression daily—individual lesions should remain fixed for at least 7 days, distinguishing EM from urticaria 2
• Watch for signs of Stevens-Johnson syndrome (widespread erythematous or purpuric macules with blisters, mucosal involvement >2 sites), which would require different management 2, 5
• Avoid nephrotoxic drugs and large volume paracentesis during the acute bleeding episode 1

Common Pitfalls to Avoid

1. Do not use systemic steroids despite the EM diagnosis—the risks (impaired hemostasis, infection, worsening portal hypertension) far outweigh any potential benefit in this setting 3, 4
2. Do not use hemostatic drugs (tranexamic acid, aminocaproic acid) for the GI bleed—they provide no benefit in cirrhotic patients and may increase thrombotic risk 6
3. Do not use infliximab or other biologics if steroid-refractory treatment is considered later, as infliximab is contraindicated in hepatic disease 3
4. Do not apply ice or prolonged cold water immersion to EM lesions despite patient desire for cooling—this risks tissue damage and ulceration 3

Once GI Bleeding is Controlled

After achieving hemostasis and hemodynamic stability (typically 5-7 days):

• Reassess the need for systemic therapy for EM if lesions are extensive or persistent 5
• Consider short-course oral corticosteroids (prednisone 0.5-1 mg/kg/day for 7-14 days) only if EM is severe and the bleeding risk has resolved 5, 3
• Initiate antiviral prophylaxis if HSV-associated recurrent EM is confirmed (acyclovir 400mg twice daily or valacyclovir 500mg daily) 2, 5
• Begin secondary prophylaxis for variceal bleeding with non-selective beta-blockers and/or repeat endoscopic band ligation 1, 3