Erythema Nodosum
Section snippets
Etiology
Erythema nodosum may be associated with a wide variety of disease processes and its observation must always be followed by a search for underlying etiology. A review of the literature reveals that the list of etiologic factors that can lead to erythema nodosum is long and varied, including infections, drugs, malignant diseases, and a wide group of miscellaneous conditions (Box 1).1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32
Pathogenesis
Erythema nodosum is considered to be a hypersensitivity response to a wide variety of inciting factors. The variability of possible antigenic stimuli that can induce erythema nodosum indicates that this disorder is a cutaneous reactive process and that the skin has limited responses to different provoking agents. Erythema nodosum probably results from the formation of immune complexes and their deposition in and around venules of the connective tissue septa of the subcutaneous fat. Circulating
Clinical features
Erythema nodosum can occur at any age, but most cases appear between the second and fourth decades of the life, with the peak of incidence between 20 and 30 years of age, probably because of the high incidence of sarcoidosis at this age.136 Several studies have demonstrated that erythema nodosum occurs three to six times more frequently in women than in men,137 although the gender incidence before puberty is approximately equal.124 Racial and geographic differences of incidence vary depending
Laboratory anomalies
Because the list of possible etiologic factors in erythema nodosum is extensive, a rational, cost-effective, diagnostic approach in patients with erythema nodosum is desirable. A complete clinical history should be elicited in all patients, with reference of previous diseases, medications, foreign travel, pets and hobbies, and familial cases.
Initial evaluation should include complete blood count, determination of the sedimentation rate, antistreptolysin O titer, urinalysis, throat culture,
Histopathology
Histopathologically, erythema nodosum is the stereotypical example of a mostly septal panniculitis with no vasculitis. The septa of subcutaneous fat are always thickened and infiltrated by inflammatory cells that extend to the periseptal areas of the fat lobules. Usually, a superficial and deep perivascular inflammatory infiltrate predominantly composed of lymphocytes is also seen in the overlying dermis. The composition of the inflammatory infiltrate in the septa varies with age of the lesion.
Prognosis
Most cases of erythema nodosum regress spontaneously in 3 to 4 weeks. More severe cases need about 6 weeks. Relapses are not exceptional, and they are more common in patients with idiopathic erythema nodosum and erythema nodosum associated with nonstreptococcal or streptococcal upper respiratory tract infections. Complications are uncommon. A patient developed retrobulbar optic nerve neuritis during the acute episode of erythema nodosum,166 and another patient with chronic hepatitis C had
Treatment
Treatment of erythema nodosum should be directed to the underlying associated condition, if identified. Usually, nodules of erythema nodosum regress spontaneously within a few weeks, and bed rest is often sufficient treatment. Aspirin and nonsteroidal anti-inflammatory drugs, such as oxyphenbutazone, 400 mg per day,168 indomethacin, 100 to 150 mg per day,169 or naproxen, 500 mg per day,170 may be helpful to enhance analgesia and resolution. If the lesions persist longer, potassium iodide in a
References (179)
Erythema nodosum
Dermatol Clin
(1985)- et al.
Septal panniculitis as a manifestation of Lyme disease
Am J Med
(1986) Erythema nodosum
Clin Dermatol
(1986)- et al.
Erythema nodosum and hepatitis B virus (HBV) infection
J Am Acad Dermatol
(1983) - et al.
Erythema nodosum and hepatitis C
Lancet
(1990) - et al.
Erythema nodosum in HIV-infected patients
J Am Acad Dermatol
(1991) - et al.
Erythema nodosum provoked by hepatitis B vaccine
Lancet
(1986) - et al.
Recurrent panniculitis in a man with asthma receiving treatment with leukotriene-modifying agents
Mayo Clin Proc
(2000) - et al.
Hyperpigmentation, neutrophilic alveolitis, and erythema nodosum resulting from minocycline
J Am Acad Dermatol
(1990) - et al.
Acne fulminans with hepatosplenomegaly and erythema nodosum migrans
J Am Acad Dermatol
(1991)
Erythema nodosum following a jellyfish sting
J Emerg Med
Histopathology of erythema nodosum in patients with coexisting lupus erythematosus
J Am Acad Dermatol
Meningitis aséptica, eritema nudoso y eritema anular centrífugo como primera manifestación de una policondritis recidivante
Med Clin (Barc)
Dermatologic conditions in patients with rheumatoid arthritis
J Am Acad Dermatol
Cutaneous vasculitis
Rickettsia conorii: una nueva causa de eritema nodoso
An Med Interna
Eritema nudoso y brucelosis
Med Clin (Barc)
Campylobacter colitis associated with erythema nodosum
Br Med J
Cat-scratch disease associated with erythema nodosum
Cutis
Psittacosis in man—recent developments in the UK: a review
Proc R Soc Med
Sweet's syndrome and erythema nodosum after Klebsiella pneumoniae cystitis
Acta Derm Venereol
Leptospirosis as a cause of erythema nodosum
Br Med J
Erythema nodosum in chlamydial infections
Acta Derm Venereol
Erythema nodosum secondary to meningococcal septicaemia
Clin Exp Dermatol
Moraxella catarrhalis bacteremia as a cause of erythema nodosum
Clin Infect Dis
Pneumopathie á mycoplasma pneumoniae avec anémie grave et érythème noueux
Presse Med
Erythema nodosum due to Pasteurella pseudotuberculosis
Br Med J
Acute ulcerative acne (acne fulminans) with erythema nodosum
Clin Exp Dermatol
Multiple painful indurated erythematous nodular skin lesions associated with Pseudomonas aeruginosa septicemia
Clin Infect Dis
Erythema nodosum and Q fever
Arch Dermatol
Salmonella gastroenteritis: another cause of erythema nodosum
Br J Dermatol
Erythema nodosum associated with Shigella colitis
Arch Dermatol
Erythema nodosum
Arch Intern Med
Syphilis: still a cause of erythema nodosum
Int J Dermatol
The changing etiology of erythema nodosum in children
Acta Tuberc Scand
Erythema nodosum rapricinene Yersinia pseudotuberculosis
Cesk Dermatol
Yersinia enterocolitica as a cause of erythema nodosum
Dermatologica
Erythema nodosum associated with acute cytomegalovirus mononucleosis in an adult
Arch Intern Med
Erythema nodosum and infectious mononucleosis
Br Med J
Erythema nodosum
Erythema nodosum and erythema multifome associated with milker's nodules
Acta Derm Venereol
Erytheme noueux associe a une infection par le parvovirus B19
Presse Med
Erythema nodosum in Singapore
Clin Exp Dermatol
Eritema nodoso: estudio de 133 casos
An Med Intern
Erythema nodosum and blastomycosis
Arch Intern Med
Erythema nodosum
JAMA
Erythema nodosum and kerion on the scalp
Am J Dis Child
Erythema nodosum in an epidemic of histoplasmosis in Indianapolis
Arch Dermatol
Erythema nodosum associated with invasive amoebiasis and giardiasis
Br J Dermatol
Eritema nudoso asociado a infección por Ascaris lumbricoides
Actas Dermosifiliogr
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2021, Diagnostic HistopathologyCitation Excerpt :Simultaneously, more than half of the patients complain of joint and muscle pain and other systemic symptoms, such as, fever, malaise, fatigue, headache, gastrointestinal problems and episcleral inflammation. Clinical variants of EN named as erythema nodosum migrans and subacute nodular migratory panniculitis belong to this histopathological spectrum.7 Histopathological hallmarks of EN are a markedly thickened septa and the presence of Miescher's radial granulomas.
Sarcoidosis presenting with and without Löfgren's syndrome: Clinical, radiological and behavioral differences observed in a group of 691 patients
2020, Joint Bone SpineCitation Excerpt :Unlike LS, pulmonary tuberculosis is usually accompanied by unilateral hilar node, exudative pleurisy in about 25%, different age distribution, and stronger positivity of tuberculin skin test. When EN is biopsied, histopathological findings vary over time, from septal edema and neutrophilic infiltrates in early stages to fibrosis, septal granulation tissue and infiltration of lymphocytes and multinucleated giant cells [56]. Remission is achieved by most of LS patients; however, chronic forms, defined by LS still active after 2 years from diagnosis, have also been described [28,31,34,36,38].
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2017, International Journal of Women's DermatologyCitation Excerpt :SSKI has various side effects, including hypothyroidism, and may require thyroid function monitoring (Johnson and Rapini, 1988). Systemic corticosteroid drugs are indicated as a second-line agent due to adverse side effects from long-term use (Requena and SanchezYus, 2008). In idiopathic cases, a more optimal treatment plan is warranted, especially in cases that are recurrent or of longer duration.