Erythema nodosum - Symptoms, Causes, Images, and Treatment Options

Diseases

Highlights & Basics

Key Highlights

Erythema nodosum presents with tender, nonulcerated, erythematous nodules located most commonly over the shins, and may sometimes be associated with arthralgia and fever.
Lesions occur as a response to a variety of conditions, including infection, chronic inflammatory disease, autoimmune disease, malignancy, and pregnancy. They are also related to the ingestion of certain medications.
Histopathology demonstrates a septal panniculitis without vasculitis. Miescher radial granulomas are a diagnostic feature, but are not necessary for confirmation.
Treatment consists of supportive care, including bed rest and leg elevation, as well as nonsteroidal anti-inflammatory drugs (NSAIDs), potassium iodide, and intralesional or oral corticosteroids. Nodules may also resolve spontaneously. Healing occurs without atrophy or scarring.

Erythema nodosum on the shin of a patient.

From the personal collection of Dr Om P. Sharma, MD, FRCP, DTM&H; used with permission

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History & Exam
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Definition

Epidemiology

Etiology

Pathophysiology

Images

Erythema nodosum lesions on skin of back due to hypersensitivity to antigens of Coccidioides immitis
Singular erythema nodosum mimicking cellulitis, the most common lesion associated with inflammatory bowel disease, ulcerative colitis, and Crohn disease (4-6% of patients, most often women ages 10-30 years)
Erythema nodosum on the shin of a patient.
Erythema nodosum on a patient's arms and hands
Erythema nodosum on a patient's arm
Erythema nodosum on a patient's arm
Pancreatic panniculitis in a 56-year-old male with neurofibromatosis 2 (NF2) and erythema nodosum (prednisone 10 mg daily)
Pancreatic panniculitis in a 56-year-old male with neurofibromatosis 2 (NF2) and erythema nodosum (prednisone 10 mg daily)
Subcutaneous panniculitis-like T cell lymphoma in a 69-year-old female with hepatitis B, thyroid cancer, and recent insect exposure while gardening
Subacute nodular migratory panniculitis
Erythema nodosum on a patient's leg

Citations

Key Articles

Bondi EE, Margolis DJ, Lazarus ZS. Panniculitis. In: Freedberg I, Eisen A, Wolff K, et al, eds. Fitzpatrick's dermatology in general medicine. 5th ed. New York, NY: McGraw-Hill; 1999: 1284-6.
Requena L, Requena C. Erythema nodosum (review). Dermatol Online J. 2002 Jun;8(1):4.[Abstract]
Sterling JB, Heymann WR. Potassium iodide in dermatology: a 19th century drug for the 21st century-uses, pharmacology, adverse effects, and contraindications. J Am Acad Dermatol. 2000 Oct;43(4):691-7.[Abstract]
Friedman ES, LaNatra N, Stiller MJ. NSAIDs in dermatologic therapy: review and preview. J Cutan Med Surg. 2002 Sep-Oct;6(5):449-59.[Abstract]
Schultz E, Whiting D. Treatment of erythema nodosum and nodular vasculitis with potassium iodides. Br J Dermatol. 1976 Jan;94(1):75-8.[Abstract]

Referenced Articles

1. Bondi EE, Margolis DJ, Lazarus ZS. Panniculitis. In: Freedberg I, Eisen A, Wolff K, et al, eds. Fitzpatrick's dermatology in general medicine. 5th ed. New York, NY: McGraw-Hill; 1999: 1284-6.
2. Requena L, Requena C. Erythema nodosum (review). Dermatol Online J. 2002 Jun;8(1):4.[Abstract]
3. Pérez-Garza DM, Chavez-Alvarez S, Ocampo-Candiani J, et al. Erythema nodosum: a practical approach and diagnostic algorithm. Am J Clin Dermatol. 2021 May;22(3):367-78.[Abstract][Full Text]
4. Blake T, Manahan M, Rodins K. Erythema nodosum - a review of an uncommon panniculitis. Dermatol Online J. 2014 Apr 16;20(4):22376.[Abstract][Full Text]
5. Kakourou T, Drosatou P, Psychou F, et al. Erythema nodosum in children: a prospective study. J Am Acad Dermatol. 2001 Jan;44(1):17-21.[Abstract]
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12. Said S, Yanuck J, Burns MJ. A case of erythema nodosum with coccidioidomycosis. Clin Pract Cases Emerg Med. 2017 Aug;1(3):251-2.[Abstract][Full Text]
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22. Starba A, Chowaniec M, Wiland P. Erythema nodosum - presentation of three cases. Reumatologia. 2016;54(2):83-5.[Abstract][Full Text]
23. Sterling JB, Heymann WR. Potassium iodide in dermatology: a 19th century drug for the 21st century-uses, pharmacology, adverse effects, and contraindications. J Am Acad Dermatol. 2000 Oct;43(4):691-7.[Abstract]
24. American Thoracic Society. Targeted tuberculin testing and treatment of latent tuberculosis infection. Am J Respir Crit Care Med. 2000 Apr;161(4 pt 2):S221-47.[Abstract][Full Text]
25. Gea-Banacloche JC, Opal SM, Jorgensen J, et al. Sepsis associated with immunosuppressive medications: an evidence-based review. Crit Care Med. 2004 Nov;32(11 suppl):S578-90.[Abstract]
26. Fardet L, Petersen I, Nazareth I. Common infections in patients prescribed systemic glucocorticoids in primary care: a population-based cohort study. PLoS Med. 2016 May;13(5):e1002024.[Abstract][Full Text]
27. Friedman ES, LaNatra N, Stiller MJ. NSAIDs in dermatologic therapy: review and preview. J Cutan Med Surg. 2002 Sep-Oct;6(5):449-59.[Abstract]
28. Schultz E, Whiting D. Treatment of erythema nodosum and nodular vasculitis with potassium iodides. Br J Dermatol. 1976 Jan;94(1):75-8.[Abstract]
29. Van Veen NH, Lockwood DN, van Brakel WH, et al. Interventions for erythema nodosum leprosum. Cochrane Database Syst Rev. 2009 Jul 8;(3):CD006949.[Abstract][Full Text]
30. Kaur I, Dogra S, Narang T, et al. Comparative efficacy of thalidomide and prednisolone in the treatment of moderate to severe erythema nodosum leprosum: a randomized study. Australas J Dermatol. 2009 Aug;50(3):181-5.[Abstract][Full Text]
31. Verma KK, Srivastava P, Minza A, et al. Role of azathioprine in preventing recurrences in a patient of recurrent erythema nodosum leprosum. Lepr Rev. 2006 Sep;77(3):225-9.[Abstract]
32. Meggitt SJ, Anstey AV, Mohd Mustapa MF, et al. British Association of Dermatologists' guidelines for the safe and effective prescribing of azathioprine 2011. Br J Dermatol. 2011 Oct;165(4):711-34.[Abstract][Full Text]
33. Yurdakul S, Mat C, Tüzün Y, et al. A double-blind trial of colchicine in Behçet's syndrome. Arthritis Rheum. 2001 Nov;44(11):2686-92.[Abstract][Full Text]
34. McEwan T, Robinson PC. A systematic review of the infectious complications of colchicine and the use of colchicine to treat infections. Semin Arthritis Rheum. 2021 Feb;51(1):101-12.[Abstract][Full Text]
35. Stewart S, Yang KCK, Atkins K, et al. Adverse events during oral colchicine use: a systematic review and meta-analysis of randomised controlled trials. Arthritis Res Ther. 2020 Feb 13;22(1):28.[Abstract][Full Text]
36. Song JS, Halim K, Vleugels RA, et al. Dapsone for treatment of erythema nodosum. Dermatol Online J. 2016 Feb 17;22(2):13030/qt8z782742.[Abstract]
37. Sharquie KE, Najim RA, Abu-Raghif AR. Dapsone in Behçet's disease: a double-blind, placebo-controlled, cross-over study. J Dermatol. 2002 May;29(5):267-79.[Abstract]
38. Boyd AS. Use of mycophenolate mofetil in erythema nodosum. J Am Acad Dermatol. 2002 Dec;47(6):968-9.[Abstract]
39. Ying S, Li S, Tang S, et al. Immune-mediated necrotizing myopathy initially presenting as erythema nodosum. J Inflamm Res. 2020;13:471-6.[Abstract][Full Text]
40. Alia E, Varma A, Brody J, et al. Use of etanercept in management of tyrosine kinase-inhibitor-induced erythema nodosum. JAAD Case Rep. 2020 Jun;6(6):567-8.[Abstract][Full Text]
41. Boyd AS. Etanercept treatment of erythema nodosum. Skinmed. 2007 Jul-Aug;6(4):197-9.[Abstract]
42. Kugathasan S, Miranda A, Nocton J, et al. Dermatologic manifestations of Crohn disease in children: response to infliximab. J Pediatr Gastroenterol Nutr. 2003 Aug;37(2):150-4.[Abstract][Full Text]
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