Erythema nodosum, a painful disorder of the subcutaneous fat, is the most common type of panniculitis. Generally, it is idiopathic, although the. Erythema nodosum (EN) is a delayed-type hypersensitivity reaction that most often presents as erythematous, tender nodules on the shins. Erythema nodosum migrans (subacute nodular migratory panniculitis, migratory panniculitis): asymmetrical, unilateral and distributed solely on.
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Erythema nodosum, a painful disorder of the subcutaneous fat, is the most common type of panniculitis. Generally, it is idiopathic, although the most common identifiable cause is streptococcal pharyngitis. Erythema nodosum may be the first sign of a systemic disease such as tuberculosis, bacterial or deep fungal infection, sarcoidosis, inflammatory bowel disease, or cancer.
Certain drugs, including oral contraceptives and some antibiotics, also nodoum be etiologic. The hallmark of erythema nodosum is tender, erythematous, subcutaneous nodules that typically are located symmetrically on the anterior surface of the lower extremities.
Erythema nodosum does not ulcerate and usually resolves without dritema or scarring. Most direct and indirect evidence supports the involvement of a type IV delayed hypersensitivity response to numerous antigens.
Erythema nodosum – Wikipedia
A deep incisional or excisional biopsy specimen should be obtained for erifema visualization. Erythema nodosum represents an inflammatory process involving the septa between subcutaneous fat lobules, with an absence of vasculitis and the presence of radial granulomas. Diagnostic evaluation after comprehensive history and physical examination includes complete blood count with differential; erythrocyte sedimentation rate, C-reactive protein level, or both; testing for streptococcal infection i.
Patients should be stratified by risk for tuberculosis. Erythema nodosum tends to be self-limited. Any underlying disorders should be treated and supportive care provided.
Pain can be managed with nonsteroidal anti-inflammatory drugs. Erythema nodosum is a type of panniculitis that affects subcutaneous fat in the skin, usually first evident as an outcropping of erythematous nodules that are highly sensitive to touch.
Although erythema nodosum usually has no specific documented cause, it is imperative to investigate possible triggers. Streptococcal infections are the most common identifiable etiology, especially in children.
Drug and hormonal reactions, inflammatory bowel disease, and sarcoidosis are other common causes among adults. Overall, erythema nodosum occurs in approximately one to five perpersons.
In adults, it is more common among women, with a male-to-female ratio of 1: The most important step in the management of erythema nodosum is treatment of the underlying disorder. Antitubercular therapy should be started presumptively for erythema nodosum in patients with a positive purified protein derivative skin test result with or without a positively identified focus eeritema infection.
In patients with erythema nodosum, pain can be managed with nonsteroidal anti-inflammatory drugs. Noxosum steroids at a dosage of 1 mg per eriyema daily may be used until resolution of erythema nodosum if underlying infection, risk of bacterial dissemination or sepsis, and malignancy have been excluded by a thorough evaluation.
For information about the SORT evidence rating system, see page or https: Erythema nodosum nodules vary from 0. Pretibial involvement is most common, although the extensor surfaces of the forearm, the thighs, and the trunk also may be affected.
Initially, erythema nodosum nodules can be firm, but they usually become more fluctuant during the clinical evolution. Individual nodules may last for two weeks; new outcroppings may continue to arise for up to six weeks. These nodules often take approximately one to two months to heal completely and may assume a bruise-like appearance as they fade.
They do not tend to ulcerate and usually resolve without atrophy or scarring. Information from references 1 through 4.
Erythema nodosum – review of the literature
Erythema nodosum classically located on pretibial surface of lower extremity. A prodrome commonly occurs as early eritmea one to three weeks before the nodosu, of erythema nodosum, regardless of the etiology. Specific symptoms may include weight loss, malaise, low-grade fever, cough, and arthralgia with or without arthritis. They are seronegative for rheumatoid factor and cause nonspecific destructive joint changes. Abnormal laboratory findings may include leukocytosis in excess nofosum 10, per mm 3 and elevated erythrocyte sedimentation rate and C-reactive protein levels.
Erythema nodosum migrans, subacute nodular migratory panniculitis, and chronic erythema nodosum, disorders classically considered distinct from erythema nodosum, now are considered to be variants in the same disease spectrum. Erythema nodosum migrans, although persistent, is minimally symptomatic and typically is first evident as unilateral nodules that tend to migrate centrifugally.
Subacute nodular migratory panniculitis is characterized by nodules on the legs that may coalesce into plaques up to nodosjm inches 20 cm in diameter. Chronic erythema nodosum can join to form larger plaques as well, although they are less inflamed compared with those of typical erythema nodosum.
These variants constitute noosum small minority of erythema nodosum cases. Erythema noddosum is a nonspecific cutaneous reaction pattern to a variety of antigens, with many immune-mediated mechanisms implicated. Erythema nodosum often occurs in association with granulomatous disease, including sarcoidosis, tuberculosis, and granulomatous colitis. A deep incisional or excisional biopsy specimen should be obtained for best visualization because a punch biopsy is likely to produce an inadequate sample.
Erythema nodosum represents an inflammation of the septa in the subcutaneous fat tissue: A neutrophilic infiltrate around proliferating capillaries results in septal thickening in early lesions that may be associated with hemorrhage.
Actinic Miescher’s radial granulomas—small, well-defined nodular aggregates of tiny histiocytes around a reitema stellate cleft—are a characteristic finding. Fibrosis, swollen venules, and granulation tissue can be seen between fat lobules and the connective tissue septa.
Physicians should consider all possible etiologies erritema erythema nodosum and take a comprehensive history. Drugs 3 to 10 percent: Complete blood count with differential; erythrocyte sedimentation rate and C-reactive protein levels. Evaluation for streptoccocal infection i. Excisional biopsy when clinical diagnosis is in doubt ; key histologic findings are septal panniculitis, lymphocytic infiltrate with neutrophils, actinic Miescher’s radial granulomas, absence of vasculitis, and no organisms.
Clinical suspicion of chronic disease e. Stool culture and evaluation for ova and parasites in patients with diarrhea or gastrointestinal symptoms; consider evaluation for inflammatory bowel disease.
Erythema nodosum – review of the literature
Information from references 1 through 46and 8. Beta-hemolytic streptococcal infections are the most common identifiable cause of erythema nodosum.
Streptococcal infections account for up to 44 npdosum of cases in adults and 48 percent of cases in children. ASO titers should be taken at the time of diagnosis and then again within four weeks to assess for streptococcal infection. Real-time PCR assays have become an attractive option eritemma the evaluation of group A streptococcal throat infections.
One PCR assay is reported to have a sensitivity of 93 percent, a specificity of 98 percent, and positive and negative predictive values of 88 and 99 percent, respectively. This assay is advocated as an effective stand-alone alternative to rapid antigen immunoassays in the evaluation of streptococcal pharyngitis. Information from nldosum 134and 6.
Erythema Nodosum: A Sign of Systemic Disease
Tuberculosis has long been linked with erythema nodosum. Furthermore, erythema nodosum may be found in patients with highly positive reactions to the Mantoux skin test but no detectable focus of tubercular infection.
All patients with erythema nodosum should be stratified by risk for tuberculosis exposure. Appropriate measures include tuberculin skin test, eritdma radiography, and acid-fast bacilli sputum analysis.
Antitubercular therapy should be initiated for erythema nodosum in patients with positive Mantoux skin test reactions with or without a positively identified focus of infection. Culture identification from primary sites of erritema also may be valuable in identifying an atypical nontuberculous mycobacterium as a cause eritemq erythema nodosum. Several atypical mycobacteria have been associated with erythema nodosum, including Mycobacterium marinumwhich may be found in swimming pools.
The patient’s geographic location and travel history should be considered. Histoplasma capsulatum, Blastomyces dermatitidis, Paracoccidioides brasiliensisand Coccidioides immitis have been implicated in the development of erythema nodosum. The incidence of erythema nodosum in patients with symptomatic coccidioidomycosis is approximately 5 percent. In these instances, erythema nodosum is preceded by upper respiratory symptoms, and its onset tends to occur before immunoglobulin M antibody serology for Coccidioides becomes positive.
However, erythema nodosum in pregnant women with coccidioidomycosis can be considered a favorable prognostic sign because dissemination of the organism beyond the lungs is less likely in these patients than in other patients with coccidioidomycosis. Other infectious etiologies of erythema nodosum are summarized in Table 2. Infectious causes of erythema nodosum occasionally involve the gastrointestinal tract, 1715 — 17 and reports indicate that the incidence of gastrointestinal infections may be increasing.
Hypersensitivity reactions to medications have been nodoosum as erihema cause of 3 to 10 percent of erythema nodosum cases. Sarcoidosis causes up to one fourth of erythema nodosum cases. Erythema nodosum occurs in up to 4. Hormone therapy also has been implicated. This decline may be a result of current at-or-below physiologic levels of 20 to 50 mcg ethinyl estradiol in oral contraceptives, although a well-defined association between estrogen and erythema nodosum has not been established.
Furthermore, there have been no reported cases of estrogen-secreting obstetric malignancies causing erythema nodosum. The relative concentration of estrogen and progesterone in nodoskm contraceptives and hormone therapy as well as during pregnancy may be more directly associated with erythema nodosum than estrogen levels alone. In addition to infectious colitis, other gastrointestinal diseases, such as ulcerative colitis and Crohn’s disease, are associated with erythema nodosum.
Erythema nodosum with abdominal pain and diarrhea may reflect acute flare-ups. Firm control of colitis may prevent further erythema nodosum; suppression of erythema nodosum in the patient may be considered an indicator for disease management. Erythema nodosum may be a cutaneous marker of malignancy, most often lymphoma or leukemia. For example, in a patient with a history of Hodgkin’s disease, the development of erythema nodosum may reflect recurrence.
Although erythema nodosum can be exquisitely tender, it tends to be self-limited. The most common approach is treatment of any underlying disorders and supportive therapy, including bed rest and avoidance of contact irritation of affected areas.
More aggressive pain management is reserved for clinical situations that become recurrent or unusually prolonged. Oral potassium iodide prepared as a supersaturated solution nodisum a dosage of to mg per day for one month is a therapeutic option. Potassium iodide therapy is more likely to be effective in providing symptomatic relief if begun eeitema the onset of the erythema nodosum.
Systemic steroids have been advocated as a relatively safe therapeutic option if underlying infection, risk of bacterial dissemination or sepsis, and malignancy have been excluded by a thorough evaluation. Oral prednisone at a dosage of 60 mg every morning is typical. A general rule is 1 mg per kg body weight per day.
Treatment also may be tailored to disease-specific regimens: