Erythema nodosum explained

Erythema nodosum
Field:Dermatology, rheumatology
Synonyms:Subacute migratory panniculitis of Vilanova and Piñol

Erythema nodosum (EN) is an inflammatory condition characterized by inflammation of subcutaneous fat tissue, resulting in painful red/blue lumps or nodules that are usually seen symmetrically on both shins, on the thighs, arms, and elsewhere.[1] It can be caused by a variety of conditions but 20 to 50% of cases are idiopathic. It typically resolves spontaneously within 30 days.[2] It is common in young people aged 12–20 years.

Signs and symptoms

Pre-eruptive phase

The first signs of erythema nodosum are often flu-like symptoms such as a fever, cough, malaise, and aching joints. Some people also experience stiffness or swelling in the joints and weight loss.[3]

Eruptive phase

Erythema nodosum is characterised by 1inches–2inchesin (–in) nodules (rounded lumps) below the skin surface, usually on the shins. These subcutaneous nodules can appear anywhere on the body, but the most common sites are the shins, arms, thighs, and torso. Each nodule typically disappears after around two weeks, though new ones may continue to form for up to six or eight weeks.[3] A new nodule usually appears red and is hot and firm to the touch. The redness starts to fade and it gradually becomes softer and smaller until it disappears. Each nodule usually heals completely without scarring over the course of about two weeks.[3] [4] Joint pain and inflammation sometimes continue for several weeks or months after the nodules appear.[5]

Less common variants of erythema nodosum include:

Causes

EN is associated with a wide variety of conditions.

Idiopathic

About 30–50% of EN cases are idiopathic (of an unknown cause).[9]

Infection

Infections associated with EN include:

Autoimmune

Autoimmune disorders associated with EN include:

Immune-mediated/Idiopathic granulomatous diseases

Pregnancy

Pregnancy may be associated with EN.

Medications

Medications associated with EN include:[9] [15]

Cancer

Cancers associated with EN include:

EN may also be due to excessive antibody production in lepromatous leprosy leading to deposition of immune complexes.[18]

There is an association with the HLA-B27 histocompatibility antigen, which is present in 65% of patients with erythema nodosum.[19]

A useful mnemonic for causes is SORE SHINS (Streptococci, OCP, Rickettsia, Eponymous (Behçet), Sulfonamides, Hansen's Disease (Leprosy), IBD, NHL, Sarcoidosis.[20]

Pathophysiology

Erythema nodosum is probably a delayed hypersensitivity reaction to a variety of antigens. Although circulating immune complexes have been demonstrated in patients with inflammatory bowel disease, they have not been found in idiopathic or uncomplicated cases.[21]

Diagnosis

Erythema nodosum is diagnosed clinically. A biopsy can be taken and examined microscopically to confirm an uncertain diagnosis.[4] Microscopic examination usually reveals a neutrophilic infiltrate surrounding capillaries that results in septal thickening, with fibrotic changes in the fat around blood vessels. A characteristic microscopic finding is radial granulomas, well-defined nodular aggregates of histiocytes surrounding a stellate cleft.

Additional evaluation should be performed to determine the underlying cause of erythema nodosum. This may include a full blood count (FBC), erythrocyte sedimentation rate (ESR), antistreptolysin-O (ASO) titer and throat culture, urinalysis, intradermal tuberculin test, and a chest x-ray.[22] The ESR is typically high, the C-reactive protein elevated, and the blood showing an increase in white blood cells.[4]

The ESR is initially very high and falls as the nodules of erythema nodosum. The ASO titer is high in cases associated with a streptococcal throat infection. A chest X-ray should be performed to rule out pulmonary diseases, in particular sarcoidosis and Löfgren syndrome.[4]

Treatment

Erythema nodosum is self-limiting and usually resolves itself within 3–6 weeks. A recurring form does exist, and in children, it is attributed to repeated infections with streptococcus.[18] Treatment should focus on the underlying cause. Symptoms can be treated with bed rest, leg elevation, compressive bandages, wet dressings, and nonsteroidal anti-inflammatory agents (NSAIDs). NSAIDs are usually more effective at the onset of EN versus with chronic disease.[23]

Potassium iodide can be used for persistent lesions whose cause remains unknown. Corticosteroids and colchicine can be used in severe refractory cases.[24] [25] Thalidomide has been used successfully in the treatment of Erythema nodosum leprosum,[26] and it was approved by the U.S. FDA for this use in July 1998.[27] According to a 2009 meta-analysis, there is some evidence of benefit for both thalidomide and clofazimine in the treatment of erythema nodosum leprosum.[28]

Epidemiology

Erythema nodosum is the most common form of panniculitis. It is most common in the ages of 20–30, and affects women 3–6 times more than men.[4]

Eponym

The term, Subacute Migratory Panniculitis of Vilanova and Piñol, was named after the two Catalan dermatologists who provided a brief description and explanation of the disease, Xavier Montiu Vilanova (1902–1965) and Joaquin Aguade Piñol (1918–1977), in 1954, and was named in 1956.[29]

Notes and References

  1. Web site: Erythema Nodosum . Johns Hopkins Medicine . 12 June 2019.
  2. Book: Pedro-Pons, Agustín. Patología y Clínica Médicas. 6. 193. 3rd. Salvat. Barcelona. 1968. es. 978-84-345-1106-4.
  3. Web site: Great Ormond Street Hospital for Children NHS Foundation Trust. Information for Families Erythema nodosum. Ref: 2012F1224. GOSH NHS Foundation Trust. April 2012. 2017-04-19. 2017-04-19. https://web.archive.org/web/20170419200521/http://www.gosh.nhs.uk/file/985/download?token=LTc63GqW. dead.
  4. Book: Fitzpatrick, Thomas B. . Fitzpatrick's color atlas and synopsis of clinical dermatology . 2005 . McGraw-Hill . New York . 978-0-07-144019-6 . 5th . 148 .
  5. 17375516 . 2007 . Schwartz . R. A. . Erythema nodosum: A sign of systemic disease . American Family Physician . 75 . 5 . 695–700 . Nervi . S. J. .
  6. 10.1111/j.1529-8019.2010.01332.x . 20666819 . Erythema nodosum and erythema induratum (nodular vasculitis): Diagnosis and management . Dermatologic Therapy . 23 . 4 . 320–7 . 2010 . Gilchrist . Heidi . Patterson . James W. . 39695627 . free .
  7. Book: Rapini, Ronald P. . Bolognia, Jean L. . Jorizzo, Joseph L. . Dermatology: 2-Volume Set . Mosby . St. Louis . 2007 . 978-1-4160-2999-1 .
  8. Book: William D. James. Timothy G. Berger. Dirk M. Elston. Andrews' Diseases of the skin : clinical dermatology.. Saunders/ Elsevier. [London]. 978-1-4377-0314-6. 11th . 488. 2011.
  9. 10.1080/00365540410027184 . 15307561 . Erythema Nodosum: An Experience of 10 Years . Scandinavian Journal of Infectious Diseases . 36 . 6–7 . 424–7 . 2009 . Mert . Ali . Ozaras . Resat . Tabak . Fehmi . Pekmezci . Salih . Demirkesen . Cuyan . Ozturk . Recep . 13123205 .
  10. Laborada . Jennifer . Cohen . Philip R . Tuberculosis-Associated Erythema Nodosum . Cureus . 2021 . 13 . 12 . e20184 . 10.7759/cureus.20184 . free . 35004007 . 8723782 .
  11. Book: 10.1016/B978-1-4557-4801-3.00252-6 . Mycobacterium leprae (Leprosy) . Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases . 2015 . Renault . Cybèle A. . Ernst . Joel D. . 2819–2831.e2 . 978-1-4557-4801-3 .
  12. Budden . Heidi . Ulloa-Gutierrez . Rolando . Dobson . Simon . Scheifele . David . Erythema Nodosum, Mycobacterium avium Lymphadenitis, and a 15-mm Mantoux Test . Pediatric Infectious Disease Journal . August 2007 . 26 . 8 . 764–765 . 10.1097/INF.0b013e31807a2fe1 . 17848899 . free .
  13. Areias . E . García E Silva . L . [Erythema nodosum and Crohn's disease] . Medicina Cutanea Ibero-latino-americana . 1984 . 12 . 6 . 489–95 . 6152299 .
  14. Katta . Rajani . Cutaneous sarcoidosis: a dermatologic masquerader. . American Family Physician . 15 April 2002 . 65 . 8 . 1581–1584 . 11989634 .
  15. 9324739 . 1997 . Bohn . S . Erythema nodosum: 112 cases. Epidemiology, clinical aspects and histopathology . Schweizerische Medizinische Wochenschrift . 127 . 27–28 . 1168–76 . Büchner . S . Itin . P .
  16. Schwartz . Robert A. . Nervi . Stephen J. . 2007-03-01 . Erythema nodosum: a sign of systemic disease . American Family Physician . 75 . 5 . 695–700 . 0002-838X . 17375516.
  17. 10.1136/bmj.301.6747.345 . 2144199 . 1663612 . Hepatitis B vaccine associated with erythema nodosum and polyarthritis . BMJ . 301 . 6747 . 345 . 1990 . Rogerson . S J . Nye . F J .
  18. Book: Vinay . Kumar . Abul K. . Abbas . Nelson . Fausto . Jon C. . Aster . Robbins and Coltran Pathological Basis of Disease . 2009 . 372–3 . Saunders/Elsevier . 978-1-4160-4930-2 .
  19. Book: Cunha, Burke A. . Infectious disease pearls . 1999 . Hanley & Belfus . Philadelphia . 978-1-56053-203-3 . 105 .
  20. Book: Wigley, J. . S. . Shantikumar . Practice Paper 4: Answers §Crohn's disease . . Get Ahead! SURGERY 100 EMQs for Finals . Taylor & Francis . 2nd . 2014 . 9781444181807 . 151 . 893164082.
  21. 16696785 . Inflammatory Bowel Disease Characteristics Among African Americans, Hispanics, and Non-Hispanic Whites: Characterization of a Large North American Cohort . The American Journal of Gastroenterology . 101 . 5 . 1012–23 . 2006 . Nguyen . Geoffrey C. . Torres . Esther A. . Regueiro . Miguel . Bromfield . Gillian . Bitton . Alain . Stempak . Joanne . Dassopoulos . Themistocles . Schumm . Philip . Gregory . Federico J. . Griffiths . Anne M. . Hanauer . Stephen B. . Hanson . Jennifer . Harris . Mary L. . Kane . Sunanda V. . Orkwis . Heather Kiraly . Lahaie . Raymond . Oliva-Hemker . Maria . Pare . Pierre . Wild . Gary E. . Rioux . John D. . Yang . Huiying . Duerr . Richard H. . Cho . Judy H. . Steinhart . A. Hillary . Brant . Steven R. . Silverberg . Mark S. . 10.1111/j.1572-0241.2006.00504.x . 7720460 .
  22. 10.1002/1529-0131(200003)43:3<584::AID-ANR15>3.0.CO;2-6 . 10728752 . Erythema nodosum: Etiologic and predictive factors in a defined population . Arthritis & Rheumatism . 43 . 3 . 584–92 . 2000 . García-Porrúa . Carlos . González-Gay . Miguel A. . Vázquez-Caruncho . Manuel . López-Lazaro . Luis . Lueiro . Mercedes . Fernández . Maria L. . Alvarez-Ferreira . Javier . Pujol . Ramón M. . free .
  23. Web site: Erythema Nodosum. The Lecturio Medical Concept Library . 24 July 2020. 21 July 2021.
  24. 10.1093/rheumatology/kei165 . 16263779 . A double-blind trial of depot corticosteroids in Behcet's syndrome . Rheumatology . 45 . 3 . 348–52 . 2005 . Mat . C. . Yurdakul . S . Uysal . S . Gogus . F . Ozyazgan . Y . Uysal . O . Fresko . I . Yazici . H . free .
  25. 10.1002/1529-0131(200111)44:11<2686::AID-ART448>3.0.CO;2-H . 11710724 . A double-blind trial of colchicine in Behçet's syndrome . Arthritis & Rheumatism . 44 . 11 . 2686–92 . 2001 . Yurdakul . Sebahattin . Mat . Cem . Tüzün . Yalçin . Özyazgan . Yilmaz . Hamuryudan . Vedat . Uysal . Ömer . Şenocak . Mustafa . Yazici . Hasan . 19523919 . free .
  26. 10.1542/peds.110.2.404 . 12165600 . The Schizophrenic Career of a 'Monster Drug' . Pediatrics . 110 . 2 . 404–6 . 2002 . Silverman . W. A. .
  27. Rouhi . Maureen . THALIDOMIDE . Chemical & Engineering News Archive . 20 June 2005 . 83 . 25 . 122 . 10.1021/cen-v083n025.p122 .
  28. Van Veen . Natasja HJ . Lockwood . Diana NJ . van Brakel . Wim H . Ramirez Jr . Jose . Richardus . Jan Hendrik . Interventions for erythema nodosum leprosum . Cochrane Database of Systematic Reviews . 8 July 2009 . 3 . CD006949 . 10.1002/14651858.CD006949.pub2 . 19588412 .
  29. 363649 . 1978 . Mascaró . J. M. . In memoriam Joaquin Piñol Aguadé, 1918--1977 . Der Hautarzt; Zeitschrift für Dermatologie, Venerologie, und Verwandte Gebiete . 29 . 11 . 613–4 .

This article is licensed under the GNU Free Documentation License. It uses material from the Wikipedia article "Erythema nodosum".

Except where otherwise indicated, Everything.Explained.Today is © Copyright 2009-2024, A B Cryer, All Rights Reserved. Cookie policy.