Updated: 10/19/2017

Erythema Nodosum

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Snapshot
  • A 33-year-old man presents with a 1-week history of a painful rash on his shins. He recently attended a music festival in the desert near California. He reports developing a rash a few days after returning back to New York. He also reports having joint pain throughout his body, particularly his knees and elbows. Physical exam reveals multiple, symmetrically distributed 1-3 cm erythematous and warm subcutaneous nodules on his anterior shins.
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
    • indication
      • 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
  • Secondary bacterial infection
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