Erythema Nodosum
Erythema Nodosum: Excerpt from The 5-Minute Pediatric Consult
Albert C. Yan, MD
Erythema Nodosum - BASICS
Erythema Nodosum - description
Delayed, cell-mediated hypersensitivity syndrome characterized by red, tender, nodular lesions that are usually on the pretibial surface of the legs and occasionally on other areas of the skin where subcutaneous fat is present
Erythema Nodosum - epidemiology
- Girls are affected more often than boys.
- Most cases are seen in the 3rd decade, but not uncommon after age 10.
Erythema Nodosum - incidence
Greatest seasonal incidence in spring and fall
Erythema Nodosum - pathophysiology
- Septal panniculitis: Lymphocytic perivascular infiltrate in the dermis; lymphocytes and neutrophils in the fibrous septa in the subcutaneous fat
- In older lesions, histiocytes, giant cells, and occasionally plasma cells are seen.
- No fat cell destruction or vasculitis is present.
Erythema Nodosum - etiology
- Thought to be a result of a host hypersensitivity immune response to circulating immune complexes secondary to infectious and/or inflammatory stimuli, which then results in chronic injury to the blood vessels of the reticular dermis and subcutaneous fat
- There are many associated triggering/underlying diseases:
- In children: Streptococcal infection and tubercular infection are the most common causes.
- In older patients: Streptococcal infection and sarcoidosis are most common; drugs (oral contraceptives, sulfonamides, iodides/bromides, phenytoin); infection (streptococcal infection, tuberculosis, psittacosis, histoplasmosis, yersiniosis, lymphogranuloma venereum, catscratch disease, coccidioidomycosis, upper respiratory infection)
- Systemic:
- Sarcoidosis
- Inflammatory bowel disease
- Hodgkin disease
- Behçet disease
- Pregnancy
Erythema Nodosum - DIAGNOSIS
Erythema Nodosum - signs & symptoms
Erythema Nodosum - history
- In >50% of patients, a history of arthralgia is noted 2–8 weeks prior.
- Prodromal symptoms of fatigue/malaise or upper respiratory infection proceed by 1–3 weeks.
- Patients often present with pain and tenderness of extremities, sometimes to the point of difficulty in ambulation.
- Special questions:
- Medication history (oral contraceptives, sulfonamides, iodides/bromides)
- Last menses (erythema nodosum is seen in pregnancy)
- History of diarrhea (inflammatory bowel disease or infectious diarrhea)
- Tuberculosis exposure
Erythema Nodosum - physical exam
- Red, often tender nodules on anterior lower legs, 2–6 cm in diameter
- Overlying skin is normal except for erythema.
- Initially, lesions are bright to deep red with palpable warmth.
- Later, lesions develop a brownish red or violaceous, bruiselike appearance.
- Smaller lesions are slope-shouldered nodules.
- Larger lesions are flat-topped plaques.
- Exam tricks:
- Erythema nodosum never ulcerates or suppurates.
- Usually, there are no more than 6 lesions at a time.
- As a rule, both legs are affected.
Erythema Nodosum - tests
Erythema Nodosum - lab
- Throat culture
- Antistreptolysin-O titer
- Purified protein derivative
- CBC
- ESR
- Stool culture, if history of diarrhea
- Serologic testing, if yersiniosis, histoplasmosis, or coccidioidomycosis suspected
Erythema Nodosum - imaging
Chest radiographic study, if diagnosis is in doubt
Erythema Nodosum - diag proced-surgery
Excisional biopsy specimen for histopathology and bacterial and fungal cultures is helpful.
Erythema Nodosum - pathological findings
False-positives: Bilateral hilar adenopathy may also be seen with sarcoidosis, coccidioidomycosis, histoplasmosis, tuberculosis, streptococcal infection, or lymphomatosis.
Erythema Nodosum - differencial diagnosis
- Infection:
- Erysipelas/cellulitis
- Superficial or deep thrombophlebitis
- Erythema induratum (nodular vasculitis)
- Deep fungal infection
- Angiitis
- Environmental (poisons)
- Tumors
- Trauma: Accidental or from child abuse
- Bruise
- Palmoplantar hidradenitis
- Metabolic:
- Panniculitis secondary to pancreatic disease
- Congenital
- Immunologic:
- Major insect bite reaction
- Psychosocial
- Sarcoidosis
- Polyarteritis nodosa
- Granuloma annulare
- Miscellaneous
- Weber-Christian (thighs and trunk) lesions may suppurate and heal with atrophy/localized depression.
Erythema Nodosum - TREATMENT
Erythema Nodosum - initial stabilization
Identification and treatment of underlying cause
Erythema Nodosum - general measures
Bed rest and leg elevation
Erythema Nodosum - medication
- Salicylates or other NSAIDs, such as ibuprofen, naproxen, or indomethacin
- Potassium iodide 300 mg PO t.i.d. for 3–4 weeks, especially for cases diagnosed early in course
- Corticosteroids are effective but rarely necessary:
Erythema Nodosum - FOLLOW UP
Erythema Nodosum - prognosis
- Most individual lesions will completely resolve in 10–14 days.
- In general, erythema nodosum resolves in 3–6 weeks with or without treatment unless the underlying cause is a chronic infection or systemic disorder.
- Aching of legs and swelling of ankles may persist for weeks; rarely, symptoms may persist for up to 2 years.
- In children, the recurrence rate is 4–10% and is often associated with repeated streptococcal infection.
Erythema Nodosum - patient monitoring
- When to expect improvement:
- Within 2–3 days
- Return visit in 1 week
- Signs to watch for: If lesions recur after cessation of treatment, underlying infection may worsen as well.
Erythema Nodosum - bibliography
Chachkin S, Cheng JW, Yan AC. Erythema nodosum. In: Burg FD, Ingelfinger JR, Polin RA, et al, eds. Current Pediatric Therapy. 18th ed. Philadelphia: WB Saunders: 2006.Hurwitz S. Clinical Pediatric Dermatology: A Textbook of Skin Disorders of Childhood and Adolescence. 2nd ed. Philadelphia: WB Saunders; 1993.- Gonzalez-Gay MA, Garcia-Porrua C, Pujol RM, et al. Erythema nodosum: A clinical approach. Clin Exp Rheumatol. 2001;19:365–368.
- Pettersson T. Sarcoid and erythema nodosum arthropathies. Best Pract Res Clin Rheumatol. 2000;14:461–476.
Erythema Nodosum - CODES
Erythema Nodosum - icd9
695.2 Erythema nodosum
Erythema Nodosum - FAQ
- Q: Will the lesions leave a scar?
- A: Erythema nodosum virtually always heals without scarring.
Book Source Details
- Book Title: The 5-Minute Pediatric Consult
- Author(s): M. William Schwartz MD; et al.
- Year of Publication: 2008
- Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: The 5-Minute Pediatric Consult
Authors: M. William Schwartz MD; et al.
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7577-9
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