Erythema nodosum

Erythema nodosum (red nodules) is an inflammation of fat cells under

the skin (panniculitis) characterized by tender red nodules or lumps
that are usually seen on both shins. Erythema nodosum 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 peak incidence of
erythema nodosum occurs between 18-36 years of age. Women are 3
- 6 times more affected than men are.
Classification
Erythema nodosum is divided into the following types:
• Acute erythema nodosum
• Chronic erythema nodosum
Clinical Presentation
Erythema nodosum usually resolves itself 3-6 weeks after occurrence
on either the internal or the external surfaces of the body that initiates
a hypersensitivity reaction in subcutaneous fat. Erythema nodosum is
frequently associated with fever, malaise, joint pain and
inflammation. It presents as tender red nodules on the shins, which are
smooth and shiny. The nodules may occur anywhere where there is
fat under the skin, including the thighs, arms, trunk, face, and neck.
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.
 Causes
In about 30-50% of cases, the cause of erythema nodosum is
unknown. Erythema nodosum 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 Bechet’s disease), pregnancy
medications (sulfonamides, oral contraceptives, bromides),
vaccinations, and cancer. Erythema nodosum may also be due to
excessive antibody production in lepromatous leprosy leading to
deposition of immune complexes. There is an association with the
HLA-B27 histocompatibility antigen, which is present in 65% of
patients with erythema nodosum.
Diagnosis
The diagnosis is clinical. A deep punch biopsy or an incisional biopsy
may be performed in cases when the diagnosis is unclear. A
microscopic examination will reveal a septal panniculitis with acute
and chronic inflammation in the fat and around blood vessels.
Once erythema nodosum is diagnosed, additional evaluation is
required to be performed for determination of an 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.
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 which is 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 infections due to streptococcus Treatment should focus on the
underlying cause. Symptoms can be treated with bed regimen, leg
elevation, compressive bandages, wet dressings, and nonsteroidal
anti- inflammatory agents (NSAIDS). NSAIDS are usually more
effective at the onset of erythema nodosum versus with a chronic
disease. Potassium iodide can be used for persistent lesions whose
cause remains unknown. Corticosteroids and colchicine can be used
in severe refractory cases.