Jump to content

Erythema nodosum

From Wikipedia, the free encyclopedia

This is an old revision of this page, as edited by 74.131.58.49 (talk) at 21:39, 5 May 2013 (→Causes). The present address (URL) is a permanent link to this revision, which may differ significantly from the current revision.

Erythema nodosum
SpecialtyDermatology Edit this on Wikidata

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.

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), vaccinations, and cancer.[10][11][12][13][14] EN may also be due to excessive antibody production in lepromatous leprosy leading to deposition of immune complexes.[15] There is an association with the HLA-B27 histocompatibility antigen, which is present in 65% of patients with erythema nodosum.[16]

A useful mnemonic for causes is SORE SHINS (Streptococci, OCP, Rickettsia, Eponymous (Bechet), Sulfonamides, Hansen's Disease (Leprosy), IBD, NHL, Sarcoidosis.

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.[17]

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.[15] 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.[18][19][20] Thalidomide has been used successfully in the treatment of Erythema nodosum leprosum,[21] and it was approved by the U.S. FDA for this use in July 1998.[22]

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 978-1-4051-4663-0. 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". 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. {{cite book}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  5. ^ Ryan TJ (1998). "Cutaneous vasculitis". In Burns DA, Breathnach SM (ed.). 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 (ed.). Fitzpatrick's Dermatology In General Medicine (6th ed.). New York, NY: McGraw-Hill. ISBN 0-07-138076-0.{{cite book}}: CS1 maint: multiple names: editors list (link)
  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.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  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.{{cite book}}: CS1 maint: multiple names: authors list (link)
  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.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  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.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  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.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  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.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  14. ^ Rogerson SJ, Nye FJ (1990-08-11). "Hepatitis B vaccine associated with erythema nodosum and polyarthritis" (PDF). BMJ. 301 (6747): 345. PMC 1663612. PMID 2144199. {{cite journal}}: More than one of |work= and |journal= specified (help)
  15. ^ a b Kumar V, Abbas A (2009). Robbins and Coltran Pathological Basis of Disease. pp. 372–373. Cite error: The named reference "Robbins" was defined multiple times with different content (see the help page).
  16. ^ Cunha, Burke. "Infections Disease Pearls" (1999), pp. 105
  17. ^ 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.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  18. ^ 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): 348–52. doi:10.1093/rheumatology/kei165. PMID 16263779.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  19. ^ Wallace SL (1967). "Erythema nodosum treatment with colchicine". JAMA. 202 (11): 1056. doi:10.1001/jama.202.11.1056b. PMID 6072607.
  20. ^ 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.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  21. ^ Silverman WA (2002). "The schizophrenic career of a "monster drug"". Pediatrics. 110 (2 Pt 1): 404–6. doi:10.1542/peds.110.2.404. PMID 12165600. {{cite journal}}: Unknown parameter |month= ignored (help)
  22. ^ Rouhi, Maureen. "Thalidomide". Chemical & Engineering News. American Chemical Society. Retrieved 2006-09-21.
Wikimedia Commons has media related to Erythema nodosum.
Retrieved from "https://en.wikipedia.org/w/index.php?title=Erythema_nodosum&oldid=553686130"