1. Overview of Supportive Care Principles

In erythema multiforme (EM), restoring the skin barrier and mitigating secondary insults are central to reducing fluid losses, pain, and infection risk. A structured approach preserves innate defenses and accelerates re‐epithelialization.

• Skin Barrier Restoration: Focus on decreasing transepidermal water loss and preventing microbial translocation.
• Pain Control: Early and effective pain management enhances tolerance of essential care, such as dressing changes and mobilization.
• Systemic Prophylaxis: Standard ICU prophylactic measures are crucial to address systemic risks that compound the morbidity of extensive EM.

2. Wound Care Management

The primary goal of wound care is to maintain a moist, protected environment that promotes epithelial growth while limiting pain and bioburden.

Assessment and Staging

• Classify lesions as target vs. non‐target and note the presence of erosions and blisters.
• Estimate the Body Surface Area (BSA) involvement to guide fluid resuscitation and analgesic dosing.

Dressing Selection

• Hydrocolloid Dressings: Support a moist healing environment; typically changed every 3–5 days.
• Non‐adherent Silicone Dressings: Minimize trauma and pain during dressing changes.
• Antimicrobial Dressings (e.g., silver‐impregnated): Reserved for wounds with high bioburden, signs of colonization, or in high-risk patients.

Application and Monitoring

• Cleanse wounds gently with isotonic saline. A thin layer of an emollient or analgesic ointment can be applied before the primary dressing.
• Secure with a non‐occlusive secondary layer and reassess skin integrity every 24–48 hours.
• Monitor for signs of infection such as increasing erythema, pain, warmth, or purulent drainage. Obtain wound cultures if systemic signs like fever or leukocytosis emerge.

3. Fluid and Electrolyte Management

Fluid resuscitation and electrolyte repletion must be tailored to cutaneous losses, insensible losses, and the patient’s overall hemodynamic status.

Quantifying Losses and Fluid Selection

• Estimating Needs: Start with baseline insensible losses (0.5–1 L/day) and add approximately 30 mL/kg per percentage of BSA involvement, using burn-based formulas as an approximation.
• Fluid Choice: Balanced crystalloids like Lactated Ringer’s are preferred to avoid the hyperchloremic metabolic acidosis associated with large volumes of normal saline. Reserve colloids for refractory hypovolemia.

Electrolyte Targets and Monitoring

• Targets: Sodium 135–145 mEq/L, Potassium 4.0–5.0 mEq/L, Magnesium ≥1.8 mg/dL.
• Repletion: Aggressively replace electrolytes. For example, administer Magnesium Sulfate 2 g IV over 2 hours if levels are <1.8 mg/dL.
• Monitoring: Check a basic metabolic panel (BMP) at least every 24 hours, monitor urine output hourly (goal ≥0.5 mL/kg/h), and obtain daily weights.

4. Pain Control Strategies

A multimodal analgesic approach is required to address both the nociceptive (inflammatory) and neuropathic components of pain from skin and mucosal lesions in EM.

Monitoring

• Assess pain scores (0–10 scale) every 4 hours and titrate to sedation targets (e.g., RASS 0 to −2).
• Monitor for respiratory depression, especially when combining opioids with ketamine or other sedatives.

5. Ocular Care and Lubrication

Aggressive lubrication and early ophthalmology involvement are critical to prevent corneal injury, scarring, and symblepharon (adhesion) formation.

Core Interventions

• Tear Supplements: Use preservative-free artificial tears hourly while the patient is awake. Apply lubricant gels or ointments (e.g., petrolatum) at bedtime.
• Anti-inflammatory/Antimicrobial Therapy: For significant inflammation, low-potency steroid drops (e.g., loteprednol 0.2% QID) may be used. If epithelial defects are present, prophylactic fluoroquinolone drops (e.g., moxifloxacin 0.5% TID) are indicated.
• Specialist Coordination: Ensure daily slit-lamp exams by an ophthalmologist. Severe cases may require escalation to amniotic membrane grafting to preserve vision.

6. Prevention of ICU-Related Complications

Patients with extensive skin loss are at high risk for common ICU complications. Applying standard prophylactic bundles is essential to mitigate these secondary risks.

7. Management of Iatrogenic Complications

Therapeutic interventions, particularly corticosteroids, can lead to predictable complications. Proactive monitoring and management are key.

A. Corticosteroid-Induced Hyperglycemia

• Mechanism & Monitoring: Steroids increase gluconeogenesis and insulin resistance. Check blood glucose Q4-6h, with frequency depending on steroid dose.
• Management: Use an insulin infusion for tight control (target 140–180 mg/dL) in the ICU. Avoid sliding-scale-only regimens. Transition to a basal-bolus regimen as steroids are tapered.

B. Secondary Infections

• Risk Factors: Breakdown of mucosal barriers, corticosteroid-induced lymphopenia, and prolonged ICU stay create a high risk for opportunistic infections.
• Prophylaxis: Consider PJP prophylaxis (e.g., TMP-SMX) for patients on steroids ≥20 mg/day for >1 month. Antifungal prophylaxis (e.g., fluconazole) may be warranted with prolonged neutropenia or broad-spectrum antibiotic use.
• Strategy: Always obtain blood and wound cultures before initiating new antimicrobials. Use procalcitonin trends to help guide antibiotic initiation and de-escalation.

8. Multidisciplinary Goals-of-Care Conversations

In severe or refractory EM, structured, empathetic dialogues are essential to ensure that the intensity of medical therapy aligns with the patient’s values and prognosis.

• Palliative Care Integration: Involve palliative care specialists early when EM is refractory, organ dysfunction progresses, or the patient’s suffering is severe.
• Documentation: Clearly document goals of care, code status, and the agreed-upon care plan in the electronic medical record. Review and confirm these goals daily.
• Pharmacist Role: The clinical pharmacist can help clarify medication burden, propose deprescribing of non-essential drugs, and educate the patient and family on the risks versus benefits of complex regimens.