Updated: 12/14/2019

Erythema Nodosum

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Snapshot
  • PhotoA 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
  • Epidemiology
    • incidence
      • the most common panniculitis
    • demographics
      • female > male
      • peak incidence between 20-30 years of age
    • risk factors
      • infection
      • autoimmune disease
      • leprosy
  • Pathogenesis
    • some evidence suggests
      • type IV delayed hypersensitivity response
      • immune complex deposition in venules of connective tissue or subcutaneous fat, causing subcutaneous nodules
  • Associated conditions
    • infection
      • coccidioidomycosis (desert bumps)
      • histoplasmosis
      • tuberculosis
      • streptococcus
      • leprosy
      • Behcet syndrome
      • Sweet syndrome
    • inflammatory bowel disease
    • sarcoidosis
  • Prognosis
    • erythema nodosum typically resolves spontaneously and fades over 1-2 months
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

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