Erythema nodosum
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| Erythema nodosum Classification and external resources | |
 | |
|---|---|
| ICD-10 | L52. |
| ICD-9 | 695.2, 017.1 |
| DiseasesDB | 4461 |
| MedlinePlus | 000881 |
| eMedicine | derm/138 |
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Overview
Erythema nodosum (EN) (red nodules) is an inflammation of the fat cells under the skin (panniculitis). It causes tender, red nodules that are usually seen on both shins. EN is an immunologic response to a variety of different causes.
Epidemiology
Erythema nodosum is the most common form of panniculitis (inflammation of the subcutaneous fat). The prevalence is 24 cases per 100,000 per year. The peak incidence of EN occurs between 20-30 years of age. Women are 3-6 times more commonly affected than men[1].
Causes
In about 30-50% of cases, the cause of EN is unknown.[2] EN may be associated with a wide variety of diseases, including infections (e.g., tuberculosis, streptococcal, Mycoplasma pneumoniae, and Epstein-Barr virus), sarcoidosis, inflammatory bowel disease, autoimmune disorders (e.g., Behçet's disease), pregnancy, medications (sulfonamides, oral contraceptives, bromides), and cancer.[2][3][4][5]
Clinical manifestations
Erythema nodosum occurs 3-6 weeks after an event, either internal or external to the body, that initiates a hypersensitivity reaction in subcutaneous fat [6][7]. EN is frequently associated with fever, malaise, arthralgia, and joint pain and inflammation. It presents as tender red nodules on the shins that are smooth and shiny. The nodules may occur anywhere there is fat under the skin, including the thighs, arms, trunk, face, and neck [8][9]. The nodules are 1-5 cm in diameter, and individual nodules may coalesce to form large areas of hardened skin.
As the nodules age, they become bluish purple, brownish, yellowish, and finally green, similar to the color changes that occur in a resolving bruise. The nodules usually subside over a period of 2–6 weeks without ulceration or scarring[1].
Dermatophytids are similar skin lesions that result from a fungus infection such as ringworm in another area of the body.
Physical Examination
Skin
Erythema Nodosum involving the lower extremity |
 Erythema Nodosum[10] |
- Lesions begin as red, tender nodules. The borders are poorly defined and they are 2 to 6 cms in diameter
- In the first week the lesions become tense, hard, and painful. In the second week, they may become fluctuant, rather like an abscess, but they do not suppurate or ulcerate. Individual lesions last around 2 weeks, but occasionally, new lesions continue to appear for 3 to 6 weeks.
- Initially, in the first week the lesions are bright red but in the second week they assume a more blue or purple hue.
- The lesions may eventually even turn yellow like a bruise which is resolving before they disappear in a several weeks.
- Usually the rash appears on the extremities, but most frequently they occur on the anterior aspect of the lower leg.
- When the underlying cause is an infection, the lesions usually heal in 6 to 8 weeks.
- If the cause is idiopathic, 30% of cases last 6 months.
Diagnosis
Diagnosis is clinical. A deep punch biopsy or an incisional biopsy may be performed in cases where the diagnosis is unclear. Microscopic examination will reveal a septal panniculitis with acute and chronic inflammation in the fat and around blood vessels[1].
Once EN is diagnosed, additional evaluation needs to be performed to determine the underlying cause. A complete blood count, erythrocyte sedimentation rate (ESR), antistreptolysin-O (ASO) titer, urinalysis, throat culture, intradermal tuberculin test, and chest x-ray is part of the initial examination.[11]
The ESR is initially very high, and falls as the nodules fade. 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. Hilar lymphadenopathy may be due to tuberculosis, sarcoidosis, or Löfgren syndrome (a form of acute sarcoidosis with erythema nodosum , parotid swelling and bilateral hilar adenopathy, often accompanied by joint symptoms).
Differential Diagnosis
E. Nodosum is indicative of an underlying infectious disease but a cause is not found in about half the cases.
- Behcet's Syndrome
- Brucellosis
- Campylobacter
- Cat-Scratch Fever
- Chlamydia
- Coccidioidomycosisimportant in the south-west USA
- Corynebacterium diphtheria
- Crohn's Disease
- Dermatophytosis
- Drugs such as sulphonylureas, gold and oral contraceptives
- Francisella tularensis
- Hepatitis
- Herpes simplex
- Histoplasmosis
- Hodgkin's Lymphoma can precede the diagnosis
- Hookworm infection
- Infectious mononucleosis
- Leprosymay closely resemble erythema nodosum but the histological findings are different
- Leptospirosis
- Leukemia
- Milker's nodule
- Mycobacterium
- Mycoplasma pneumoniae
- Neisseria Meningitidis
- North American Blastomycosis
- Postradiated pelvic cancer
- Pregnancy usually in the second trimester. Often recurs during future pregnancies and may occur with oral contraceptive uses
- Radiation therapy
- Reiter's Disease
- Salmonella
- Sarcoidosis
- Sporotrichosis
- Streptococcal infections are one of the most common causes
- Toxoplasmosis
- Tuberculosis
- Ulcerative colitis
- Yersinia
Treatment
Treatment should focus on the underlying cause. Symptoms can be treated with bedrest, leg elevation, compressive bandages, wet dressings, and nonsteroidal anti-inflammatory agents (NSAIDs).[1] NSAIDS are usually more effective at the onset of EN versus with chronic disease. Steroids can be of benefit but may be contraindicated if infection is present. In erythema nodosum associated with leprosy, thalidomide may be helpful.
Potassium iodide can be used for persistent lesions whose cause remains unknown. Corticosteroids and colchicine can be used in severe refractory cases (Yurdakul et al, 2001).[12][13][14]
References
- ↑ 1.0 1.1 1.2 1.3 Wolff K, Johnson RA, Suurmond R (2005). "Section 7: Miscellaneous inflammatory disorders", Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology, 5th ed., New York, NY: McGraw-Hill Professional. ISBN 0-07-144019-4.
- ↑ 2.0 2.1 Mert A, Ozaras R, Tabak F, Pekmezci S, Demirkesen C, Ozturk R (2004). "Erythema nodosum: an experience of 10 years". Scand J Infect Dis 36 (6-7): 424-7. PMID 15307561.
- ↑ Anan T, Imamura T, Yokoyama S, Fujiwara S (2004). "Erythema nodosum and granulomatous lesions preceding acute myelomonocytic leukemia". J Dermatol 31 (9): 741-7. PMID 15628321.
- ↑ Bohn S, Buchner S, Itin P (1997). "[Erythema nodosum: 112 cases. Epidemiology, clinical aspects and histopathology]". Schweiz Med Wochenschr 127 (27-28): 1168-76. PMID 9324739.
- ↑ Lin JT, Chen PM, Huang DF, Kwang WK, Lo K, Wang WS (2004). "Erythema nodosum associated with carcinoid tumour". Clin Exp Dermatol 29 (4): 426-7. PMID 15245549.
- ↑ Ryan TJ (1998). "Cutaneous vasculitis", in Burns DA, Breathnach SM: Textbook of Dermatology, 6th ed., London: Blackwell Science Ltd, 2155-225. ISBN 0-632-05064-0.
- ↑ Camilleri MJ, Su WPD (2003). "Panniculitis", in Freedberg IM, Eisen AZ, Wolff K, Austen KF, Goldsmith LA, Katz SI: Fitzpatrick's Dermatology In General Medicine, 6th ed., New York, NY: McGraw-Hill. ISBN 0-07-138076-0.
- ↑ Cribier B, Caille A, Heid E, Grosshans E (1998). "Erythema nodosum and associated diseases. A study of 129 cases". Int J Dermatol 37 (9): 667-72. PMID 9762816.
- ↑ White WL, Hitchcock MG (1999). "Diagnosis: erythema nodosum or not?". Semin Cutan Med Surg 18 (1): 47-55. PMID 10188842.
- ↑ http://picasaweb.google.com/mcmumbi/USMLEIIImages
- ↑ Garcia-Porrua C, Gonzalez-Gay MA, Vazquez-Caruncho M, Lopez-Lazaro L, Lueiro M, Fernandez ML, Alvarez-Ferreira J, Pujol RM (2000). "Erythema nodosum: etiologic and predictive factors in a defined population". Arthritis Rheum 43 (3): 584-92. PMID 10728752.
- ↑ Mat C, Yurdakul S, Uysal S, Gogus F, Ozyazgan Y, Uysal O, Fresko I, Yazici H (2005). "A double-blind trial of depot corticosteroids in Behcet's syndrome". Rheumatology (Oxford). PMID 16263779.
- ↑ Wallace SL (1967). "Erythema nodosum treatment with colchicine". JAMA 202 (11): 1056. PMID 6072607.
- ↑ Yurdakul S, Mat C, Tuzun Y, Ozyazgan Y, Hamuryudan V, Uysal O, Senocak M, Yazici H (2001). "A double-blind trial of colchicine in Behcet's syndrome". Arthritis Rheum 44 (11): 2686-92. PMID 11710724.
Additional Resource
- Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:131-132 ISBN 1591032016
External Links
de:Erythema nodosumet:Nodoosne erüteemfi:Kyhmyruusu ja:結節性紅斑
Acknowledgement and Attribution Regarding Sources of Content
Some of the initial content on this page may be incorporated in part from copyleft sources in the public domain including wikis such as Wikipedia and AskDrWiki. Drug information for patients came from the The National Library of Medicine. Infectious disease information may have come from the Centers for Disease Control (CDC). Differential Diagnoses are drawn from clinicians as well as an amalgamation of 3 sources: 1.The Disease Database; 2. Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:3; 3. Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:7 .
