Erythema nodosum

Erythema nodosum
Erythema nodosum
Classification and external resources

Erythema nodosum in a person who had recently had streptococcal pharyngitis
ICD-10 L52
ICD-9 695.2, 017.1
DiseasesDB 4462
MedlinePlus 000881
eMedicine derm/138
MeSH D004893

Erythema nodosum (EN) (red nodules) is an inflammation of the fat cells under the skin (panniculitis)[1] characterized by tender[2] red nodules[3] or lumps[2] that are usually seen on both shins.[2] EN is an immunologic response to a variety of different causes.

Contents

Classification

Erythema nodosum may be divided into the following types:[4]:488

Signs and symptoms

Erythema nodosum lesion in a person with tuberculosis.
A single lesion of erythema nodosum

Erythema nodosum usually resolves itself 3–6 weeks after an event, either internal or external to the body, that initiates a hypersensitivity reaction in subcutaneous fat.[5][6] EN is frequently associated with fever, malaise, 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.[7][8] The nodules are 1–10 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.[9]

Dermatophytids are similar skin lesions that result from a fungus infection such as ringworm in another area of the body.

Causes

In about 30-50% of cases, the cause of EN is unknown.[10] EN may be associated with a wide variety of diseases, including infections (e.g., hepatitis C, tuberculosis, streptococcal, Mycoplasma pneumoniae, Yersinia, and Epstein-Barr virus), Coccidioides immitis, sarcoidosis, autoimmune disorders (e.g., Inflammatory bowel disease or Behçet's disease), pregnancy, medications (sulfonamides, oral contraceptives, bromides), and cancer.[10][11][12][13] EN may also be due to excessive antibody production in lepromatous leprosy leading to deposition of immune complexes.[14] There is an association with the HLA-B27 histocompatibility antigen, which is present in 65% of patients with erythma nodosum.[15]

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.[9]

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 are part of the initial examination.[16]

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, bilateral hilar adenopathy, fever and often accompanied by joint symptoms).

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.[14] 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).[9] NSAIDs are usually more effective at the onset of EN versus with chronic disease.

Potassium iodide can be used for persistent lesions whose cause remains unknown. Corticosteroids and colchicine can be used in severe refractory cases.[17][18][19] Thalidomide has been used successfully in the treatment of Erythema nodosum leprosum,[20] and it was approved by the U.S. FDA for this use in July 1998.[21]

Epidemiology

Erythema nodosum is the most common form of panniculitis (inflammation of the subcutaneous fat). The peak incidence of EN occurs between 18–36 years of age. Women are 3-6 times more affected than men.[9]

References

  1. ^ Richard P. J. B. Weller; J. A. A. Hunter; Mark Dahl (21 March 2008). Clinical Dermatology. John Wiley and Sons. pp. 112–. ISBN 9781405146630. http://books.google.com/?id=5RHM0Nerk9gC&pg=PA112. Retrieved 8 May 2010. 
  2. ^ a b c thefreedictionary.com > erythema nodosum Citing: Gale Encyclopedia of Medicine. 2008 The Gale Group
  3. ^ "MerckMedicus : Dorland's Medical Dictionary". http://merckmedicus.com/pp/us/hcp/thcp_dorlands_content_split.jsp?pg=/ppdocs/us/common/dorlands/drlnd/three_08/000036718.htm#000036718. Retrieved 2009-02-26. 
  4. ^ James, William D.; Berger, Timothy G.; et al. (2006). Andrews' Diseases of the Skin: clinical Dermatology. Saunders Elsevier. ISBN 0-7216-2921-0. 
  5. ^ Ryan TJ (1998). "Cutaneous vasculitis". In Burns DA, Breathnach SM. Textbook of Dermatology (6th ed.). London: Blackwell Science Ltd. pp. 2155–225. ISBN 0-632-05064-0. 
  6. ^ 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. 
  7. ^ 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. doi:10.1046/j.1365-4362.1998.00316.x. PMID 9762816. 
  8. ^ White WL, Hitchcock MG (1999). "Diagnosis: erythema nodosum or not?". Semin Cutan Med Surg 18 (1): 47–55. doi:10.1016/S1085-5629(99)80008-X. PMID 10188842. 
  9. ^ a b c d 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. 
  10. ^ a b 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. doi:10.1080/00365540410027184. PMID 15307561. 
  11. ^ 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. 
  12. ^ 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. 
  13. ^ 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. doi:10.1111/j.1365-2230.2004.01544.x. PMID 15245549. 
  14. ^ a b Kumar V, Abbas A (2009). Robbins and Coltran Pathological Basis of Disease. pp. 372–373. 
  15. ^ Cunha, Burke. "Infections Disease Pearls" (1999), pp. 105
  16. ^ 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. doi:10.1002/1529-0131(200003)43:3<584::AID-ANR15>3.0.CO;2-6. PMID 10728752. 
  17. ^ 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) 45 (3): 348. doi:10.1093/rheumatology/kei165. PMID 16263779. 
  18. ^ Wallace SL (1967). "Erythema nodosum treatment with colchicine". JAMA 202 (11): 1056. doi:10.1001/jama.202.11.1056b. PMID 6072607. 
  19. ^ 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. doi:10.1002/1529-0131(200111)44:11<2686::AID-ART448>3.0.CO;2-H. PMID 11710724. 
  20. ^ Silverman WA (August 2002). "The schizophrenic career of a "monster drug"". Pediatrics 110 (2 Pt 1): 404–6. doi:10.1542/peds.110.2.404. PMID 12165600. 
  21. ^ Rouhi, Maureen. "Thalidomide". Chemical & Engineering News. American Chemical Society. http://pubs.acs.org/cen/coverstory/83/8325/8325thalidomide.html. Retrieved 2006-09-21. 
v · d · eUrticaria and erythema (L50–L54, 695, 708)
Urticaria
(acute/chronic)
Allergic urticaria
Urticarial allergic eruption
Physical urticaria
Cold urticaria (Familial) · Primary cold contact urticaria · Secondary cold contact urticaria · Reflex cold urticaria
Heat urticaria · Localized heat contact urticaria · Solar urticaria
Vibratory angioedema · Pressure urticaria
Aquagenic urticaria
Other urticaria
Acquired C1 esterase inhibitor deficiency · Adrenergic urticaria · Exercise urticaria · Galvanic urticaria · Schnitzler syndrome · Urticaria-like follicular mucinosis
Episodic angioedema with eosinophilia · Hereditary angioedema
Erythema
Erythema multiforme minor · Erythema multiforme major (Stevens–Johnson syndrome, Toxic epidermal necrolysis) · panniculitis (Erythema nodosum) · Acute generalized exanthematous pustulosis
Figurate erythema
Other erythema
Necrolytic migratory erythema · Erythema toxicum · Erythroderma · Palmar erythema · Generalized erythema

M: INT, SF, LCT

anat/phys/devp

noco(i/b/d/q/u/r/p/m/k/v/f)/cong/tumr(n/e/d), sysi/epon

proc, drug (D2/3/4/5/8/11)
v · d · eDisorders of subcutaneous fat (M79.3, 729.3)
Panniculitis
Lobular
without vasculitis: Cytophagic histiocytic panniculitis · Factitial panniculitis · Gouty panniculitis · Pancreatic panniculitis · Traumatic panniculitis (Cold panniculitis) · needle-shaped clefts (Subcutaneous fat necrosis of the newborn, Sclerema neonatorum, Post-steroid panniculitis) · Lipodermatosclerosis · Weber–Christian disease · Lupus erythematosus panniculitis · Sclerosing lipogranuloma
with vasculitis: Nodular vasculitis/Erythema induratum
Septal
without vasculitis: Alpha-1 antitrypsin deficiency panniculitis · Erythema nodosum (Acute erythema nodosum, Chronic erythema nodosum)
with vasculitis: Superficial thrombophlebitis
Lipodystrophy
Acquired

generalized: Acquired generalized lipodystrophy

partial: Acquired partial lipodystrophy · Centrifugal abdominal lipodystrophy · HIV-associated lipodystrophy · Lipoatrophia annularis

localized: Localized lipodystrophy
Congenital

Congenital generalized lipodystrophy · Familial partial lipodystrophy

Poland's syndrome

M: INT, SF, LCT

anat/phys/devp

noco(i/b/d/q/u/r/p/m/k/v/f)/cong/tumr(n/e/d), sysi/epon

proc, drug (D2/3/4/5/8/11)

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Look at other dictionaries:

  • Erythema nodosum — Klassifikation nach ICD 10 L52 Erythema nodosum …   Deutsch Wikipedia

  • erythema nodosum — noun skin condition characterized by tender red nodules on the shins and legs • Hypernyms: ↑erythema • Hyponyms: ↑erythema nodosum leprosum, ↑ENL * * * nōˈdōsəm noun Etymology: New Latin …   Useful english dictionary

  • erythema nodosum — erythema no·do·sum nō dō səm n a skin condition characterized by small tender reddened nodules under the skin (as over the shin bones) often accompanied by fever and transitory arthritic pains and commonly considered a manifestation of… …   Medical dictionary

  • Erythema nodosum — Erythema contusiforme (fachsprachlich); Dermatitis contusiforme (fachsprachlich); Knotenrose …   Universal-Lexikon

  • erythema nodosum leprosum — noun an inflammatory complication of leprosy that results in painful skin lesions on the arms and legs and face • Syn: ↑ENL • Hypernyms: ↑erythema nodosum • Part Holonyms: ↑leprosy, ↑Hansen s disease …   Useful english dictionary

  • erythema nodosum — Eruption of pink or red nodules, usually on the lower limbs as a result of infection with any of a range of bacteria, viruses or fungi. Often associated with IBD and in some parts of the world is commonly associated with lepromatous leprosy …   Dictionary of molecular biology

  • Chronic erythema nodosum — (also known as Erythema nodosum migrans, [1] Subacute migratory panniculitis of Vilanova and Piñol ,[1] and Subacute nodular migratory panniculitis [2]) is a form of septal panniculitis that is much less common than acute erythema nodosum.[1]:488 …   Wikipedia

  • erythema nodosum leprosum — the type 1 kind of lepra reaction; it resembles an Arthus reaction, and usually occurs during chemotherapy for lepromatous or borderline lepromatous leprosy, although occasionally it appears spontaneously. It is usually characterized by… …   Medical dictionary

  • erythema nodosum migrans — subacute nodular migratory panniculitis …   Medical dictionary

  • Erythema multiforme — Classification and external resources Erythema multiforme minor of the hands ( note the blanching centers of the lesion ) ICD 10 L …   Wikipedia

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