Erythema nodosum 2949731 222659824 2008-06-30T14:04:03Z 192.48.179.6 {{DiseaseDisorder infobox | Name = Erythema nodosum | ICD10 = {{ICD10|L|52||l|50}} | ICD9 = {{ICD9|695.2}}, {{ICD9|017.1}} | DiseasesDB = 4461 | MedlinePlus = 000881 | eMedicineSubj = derm | eMedicineTopic = 138 | }} '''Erythema nodosum (EN)''' (''red nodules'') is an [[inflammation]] of the fat cells under the skin ([[panniculitis]]). It causes tender, red nodules that are usually seen on both shins. EN is an immunologic response to a variety of different causes. ==Clinical manifestations== Erythema nodosum usually resolves itself 3-6 weeks after an event, either internal or external to the body, that initiates a [[hypersensitivity]] reaction in [[subcutaneous]] fat <ref>{{cite book | author = Ryan TJ | year = 1998 | title = Textbook of Dermatology | chapter = Cutaneous vasculitis | editor = Burns DA, Breathnach SM | edition = 6th ed. | publisher = Blackwell Science Ltd | location = London | pages = 2155-225 | id = ISBN 0-632-05064-0}}</ref><ref>{{cite book | author = Camilleri MJ, Su WPD | year = 2003 | title = Fitzpatrick's Dermatology In General Medicine | chapter = Panniculitis | editor = Freedberg IM, Eisen AZ, Wolff K, Austen KF, Goldsmith LA, Katz SI | edition = 6th ed. | publisher = McGraw-Hill | location = New York, NY | id = ISBN 0-07-138076-0}}</ref>. EN is frequently associated with fever, malaise, and joint pain and inflammation. It presents as tender red nodules on the shins that are smooth and shiny. The nodules may occur anywhere there is fat under the skin, including the thighs, arms, trunk, face, and neck <ref>{{cite journal | author = Cribier B, Caille A, Heid E, Grosshans E | title = Erythema nodosum and associated diseases. A study of 129 cases | journal = Int J Dermatol | year = 1998 | pages = 667–72 | volume = 37 | issue = 9 | pmid = 9762816 | doi = 10.1046/j.1365-4362.1998.00316.x}}</ref><ref>{{cite journal | author = White WL, Hitchcock MG | title = Diagnosis: erythema nodosum or not? | journal = Semin Cutan Med Surg | year = 1999 | pages = 47–55 | volume = 18 | issue = 1 | pmid = 10188842 | doi = 10.1016/S1085-5629(99)80008-X}}</ref>. The nodules are 1-5 cm in diameter, and individual nodules may coalesce to form large areas of hardened skin. As the nodules age, they become bluish purple, brownish, yellowish, and finally green, similar to the color changes that occur in a resolving bruise. The nodules usually subside over a period of 2–6 weeks without ulceration or scarring<ref name="Wolff">{{cite book | author = Wolff K, Johnson RA, Suurmond R | year = 2005 | title = Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology | chapter = Section 7: Miscellaneous inflammatory disorders | edition = 5th ed. | publisher = McGraw-Hill Professional | location = New York, NY | id = ISBN 0-07-144019-4}}</ref>. [[Dermatophytids]] are similar skin lesions that result from a fungus infection such as [[ringworm]] in another area of the body. ==Diagnosis== Diagnosis is clinical. A deep punch biopsy or an incisional biopsy may be performed in cases where the diagnosis is unclear. Microscopic examination will reveal a septal panniculitis with acute and chronic inflammation in the fat and around blood vessels<ref name="Wolff"/>. Once EN is diagnosed, additional evaluation needs to be performed to determine the underlying cause. A complete blood count, [[erythrocyte sedimentation rate]] (ESR), [[Antistreptolysin O titre|antistreptolysin-O (ASO) titer]], [[urinalysis]], throat culture, intradermal tuberculin test, and chest x-ray is part of the initial examination.<ref>{{cite journal | author = Garcia-Porrua C, Gonzalez-Gay MA, Vazquez-Caruncho M, Lopez-Lazaro L, Lueiro M, Fernandez ML, Alvarez-Ferreira J, Pujol RM | title = Erythema nodosum: etiologic and predictive factors in a defined population | journal = Arthritis Rheum | year = 2000 | pages = 584–92 | volume = 43 | issue = 3 | pmid = 10728752 | doi = 10.1002/1529-0131(200003)43:3<584::AID-ANR15>3.0.CO;2-6}}</ref> The ESR is initially very high, and falls as the nodules fade. The ASO titer is high in cases associated with a streptococcal throat infection. A [[chest X-ray]] should be performed to rule out [[pulmonary]] diseases. [[Hilum|Hilar]] [[lymphadenopathy]] may be due to tuberculosis, [[sarcoidosis]], or [[Löfgren syndrome]] (a form of acute sarcoidosis with erythema nodosum , [[parotid]] swelling and bilateral hilar adenopathy, often accompanied by joint symptoms). ==Epidemiology== Erythema nodosum is the most common form of panniculitis (inflammation of the subcutaneous fat). The peak incidence of EN occurs between 20-30 years of age. Women are 3-6 times more commonly affected than men<ref name="Wolff"/>. ==Causes== In about 30-50% of cases, the cause of EN is unknown.<ref name="Mert">{{cite journal | author = Mert A, Ozaras R, Tabak F, Pekmezci S, Demirkesen C, Ozturk R | title = Erythema nodosum: an experience of 10 years | journal = Scand J Infect Dis | year = 2004 | pages = 424–7 | volume = 36 | issue = 6-7 | pmid = 15307561 | doi = 10.1080/00365540410027184}}</ref> EN may be associated with a wide variety of diseases, including infections (e.g., [[tuberculosis]], [[streptococcal]], Mycoplasma pneumoniae, and [[Epstein-Barr virus]]), [[sarcoidosis]], [[inflammatory bowel disease]], autoimmune disorders (e.g., [[Behçet's disease]]), pregnancy, medications ([[sulfonamides]], oral contraceptives, bromides), and cancer.<ref name="Mert"/><ref>{{cite journal | author = Anan T, Imamura T, Yokoyama S, Fujiwara S | title = Erythema nodosum and granulomatous lesions preceding acute myelomonocytic leukemia | journal = J Dermatol | year = 2004 | pages = 741–7 | volume = 31 | issue = 9 | pmid = 15628321}}</ref><ref>{{cite journal | author = Bohn S, Buchner S, Itin P | title = [Erythema nodosum: 112 cases. Epidemiology, clinical aspects and histopathology] | journal = Schweiz Med Wochenschr | year = 1997 | pages = 1168–76 | volume = 127 | issue = 27-28 | pmid = 9324739}}</ref><ref>{{cite journal | author = Lin JT, Chen PM, Huang DF, Kwang WK, Lo K, Wang WS | title = Erythema nodosum associated with carcinoid tumour | journal = Clin Exp Dermatol | year = 2004 | pages = 426–7 | volume = 29 | issue = 4 | pmid = 15245549 | doi = 10.1111/j.1365-2230.2004.01544.x}}</ref> ==Treatment== Treatment should focus on the underlying cause. Symptoms can be treated with bedrest, leg elevation, compressive bandages, wet dressings, and nonsteroidal anti-inflammatory agents (NSAIDs).<ref name="Wolff"/> NSAIDS are usually more effective at the onset of EN versus with chronic disease. [[Potassium iodide]] can be used for persistent lesions whose cause r<!-- <ref>Comment</ref>[[[http://www.example.com link title]]'''''Italic text'''''] -->emains unknown. Corticosteroids and colchicine can be used in severe refractory cases (Yurdakul et al, 2001).<ref>{{cite journal | author = Mat C, Yurdakul S, Uysal S, Gogus F, Ozyazgan Y, Uysal O, Fresko I, Yazici H | title = A double-blind trial of depot corticosteroids in Behcet's syndrome | journal = Rheumatology (Oxford) | year = 2005 | pmid = 16263779 | doi = 10.1093/rheumatology/kei165 | volume = 45 | pages = 348}}</ref><ref>{{cite journal | author = Wallace SL | title = Erythema nodosum treatment with colchicine | journal = JAMA | year = 1967 | pages = 1056 | volume = 202 | issue = 11 | pmid = 6072607 | doi = 10.1001/jama.202.11.1056b}}</ref><ref>{{cite journal | author = Yurdakul S, Mat C, Tuzun Y, Ozyazgan Y, Hamuryudan V, Uysal O, Senocak M, Yazici H | title = A double-blind trial of colchicine in Behcet's syndrome | journal = Arthritis Rheum | year = 2001 | pages = 2686–92 | volume = 44 | issue = 11 | pmid = 11710724 | doi = 10.1002/1529-0131(200111)44:11<2686::AID-ART448>3.0.CO;2-H}}</ref> ==External links== * [http://www.geocities.com/erythema_nodosum/] Erythema Nodosum information ==References== {{Reflist|2}} {{Diseases of the skin and subcutaneous tissue}} [[Category:Autoimmune diseases]] [[Category:Dermatology]] [[de:Erythema nodosum]] [[et:Nodoosne erüteem]] [[pl:Rumień guzowaty]] [[fi:Kyhmyruusu]] [[sv:Knölros]]