Fever After Prednisolone Discontinuation in Erythema Multiforme

Understanding the Clinical Context

Adrenal suppression does not occur with 2-day prednisolone courses, as the hypothalamic-pituitary-adrenal axis requires prolonged exposure (typically >2 weeks) before suppression becomes clinically significant 1
Rebound inflammation is extremely unlikely after such short-duration therapy, as this phenomenon typically occurs with abrupt cessation after prolonged courses (>7-10 days) 2
Steroid withdrawal fever is not a recognized entity in pediatric literature following brief therapeutic courses 3, 1

The fever may represent the underlying infectious process that initially triggered the erythema multiforme, which was masked by the anti-inflammatory effects of prednisolone 2
High fever (104°F/40°C) is more consistent with active infection than drug reaction 4, 5
The American College of Rheumatology emphasizes that persistent fever with ongoing end-organ involvement requires escalation of therapy 4, 5

Perform urgent assessment for infectious workup, including complete blood count with differential, blood cultures, urinalysis and culture, and chest radiograph if respiratory symptoms present 4, 5
Evaluate for new bullae formation, epidermal sloughing, or increased body surface area involvement 1
Assess systemic inflammation using C-reactive protein and erythrocyte sedimentation rate 4, 5

If infection is identified, treat the specific pathogen appropriately and consider restarting prednisolone 1 mg/kg/day only if skin lesions are worsening despite antimicrobial therapy 1
If no infection found but skin disease is progressing, restart prednisolone at 1-2 mg/kg/day as a single morning dose (maximum 60 mg/day) 1
For severe progression with >30% body surface area involvement, consider dermatology consultation same-day 1
If truly refractory, escalation to methylprednisolone 1-2 mg/kg/day IV may be warranted 3

Do not assume the fever is "steroid withdrawal" – this is not a recognized phenomenon after 2-day courses and may delay diagnosis of serious infection 3, 1
Do not restart steroids empirically without ruling out infection – corticosteroids will mask fever and blunt the immune response, potentially allowing infections to progress unchecked 2
Do not discharge without identifying fever source – 104°F in an 18-month-old warrants thorough evaluation regardless of recent medication changes 4, 5