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Updated: Oct 19 2017

Erythema Nodosum

  • 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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