Updated: 12/16/2021

Erythema Nodosum

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  • Snapshot
    • A 25-year-old woman with a history of sarcoidosis presents with fever, fatigue, and joint pain over the past week. Yesterday, she developed a bruise-like and raised painful rash on her shins despite having no recent trauma to the area. Physical exam reveals multiple 2-4 cm erythematous and tender nodules with poorly demarcated borders on her anterior shins. Laboratory examination reveals elevated inflammatory markers. She is sent home with reassurance and instructions to take ibuprofen as needed for pain.
  • Introduction
    • Clinical definition
      • a panniculitis characterized by painful subcutaneous nodules typically located on pretibial surfaces
    • Associated conditions
      • infection
        • coccidioidomycosis (desert bumps)
        • histoplasmosis
        • tuberculosis
        • streptococcus
        • leprosy
        • Behcet syndrome
        • Sweet syndrome
      • inflammatory bowel disease
      • sarcoidosis
  • Epidemiology
    • Incidence
      • the most common panniculitis
    • Demographics
      • female > male
      • peak incidence between 20-30 years of age
    • Risk factors
      • infection
      • autoimmune disease
      • leprosy
  • ETIOLOGY
    • Pathogenesis
      • some evidence suggests
        • type IV delayed hypersensitivity response
        • immune complex deposition in venules of connective tissue or subcutaneous fat, causing subcutaneous nodules
  • Presentation
    • Symptoms
      • sudden onset painful symmetric rash
      • often preceded by inflammation/infection
      • may be preceded by prodrome
        • fever, malaise, and fatigue
        • arthralgia
    • Physical exam
      • warm and erythematous subcutaneous nodules that are 1-10 cm in diameter
        • tender to palpation
      • poorly demarcated margins
      • location
        • typically symmetrically on anterior shins
        • can also affect forearms, thighs, trunk, head, or neck
  • Studies
    • Labs
      • ↑ inflammatory markers
        • erythrocyte sedimentation rate
        • C-reactive protein
    • Biopsy
      • indications
        • only if diagnosis is unclear clinically
    • Histology
      • septal panniculitis without vasculitis
        • septa is thickened and has inflammatory infiltration
  • Differential
    • Scleroderma
    • Granulomas
  • Treatment
    • Management approach
      • treat underlying cause
    • Medical
      • nonsteroidal anti-inflammatory drugs (NSAIDs)
        • indication
          • for symptomatic relief as needed
  • Complications
    • Arthralgias may persist
    • Secondary bacterial infection
  • Prognosis
    • Erythema nodosum typically resolves spontaneously and fades over 1-2 months
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