Erythema Nordosum

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Erythema nodosuma.streptococcal infectionb.IEc.painful on the shind.occurrs in hands and thighs

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Erythema nodosum (EN) is an acute, nodular, erythematous eruption that usually is limited to the extensor aspects of the lower legs. Chronic or recurrent erythema nodosum is rare but may occur. Erythema nodosum is presumed to be a hypersensitivity reaction and may occur in association with several systemic diseases or drug therapies, or it may be idiopathic. The inflammatory reaction occurs in the panniculus.PathophysiologyErythema nodosum probably is a delayed hypersensitivity reaction to a variety of antigens; circulating immune complexes have not been found in idiopathic or uncomplicated cases but may be demonstrated in patients with inflammatory bowel disease. [1]EtiologyCurrently, the most common cause of erythema nodosum is streptococcal infection in children and streptococcal infection and sarcoidosis in adults. [2] Numerous other causes have been reported. [3] The causes reported most often in the literature are described below.Bacterial infectionsStreptococcal infections are one of the most common causes of erythema nodosum. [4] Tuberculosis was an important cause in the past, but it has decreased dramatically as a cause for erythema nodosum; however, it still must be excluded, especially in developing countries. [5, 6] Yersinia enterocolitica is a gram-negative bacillus that causes acute diarrhea and abdominal pain; it is a common cause of erythema nodosum in France and Finland. [7, 8, 9] Mycoplasma pneumoniae infection may cause erythema nodosum. Erythema nodosum leprosum clinically resembles erythema nodosum, but the histologic picture is that of leukocytoclastic vasculitis. Lymphogranuloma venereum may cause erythema nodosum. Salmonella infection may cause erythema nodosum. Campylobacter infection may cause erythema nodosum.Fungal infectionsCoccidioidomycosis (San Joaquin Valley fever) is the most common cause of erythema nodosum in the American Southwest. In approximately 4% of males and 10% of females, the primary fungal infection (which may be asymptomatic or involve symptoms of upper respiratory infection) is followed by the development of erythema nodosum. Lesions appear 3 days to 3 weeks after the end of the fever caused by the fungal infection. Histoplasmosis may cause erythema nodosum. Blastomycosis may cause erythema nodosum.DrugsSulfonamides and halide agents are an important cause of erythema nodosum. Drugs more recently described to cause erythema nodosum include gold and sulfonylureas. Oral contraceptive pills are implicated in an increasing number of reports. [10]EnteropathiesUlcerative colitis and Crohn disease may trigger erythema nodosum. Erythema nodosum associated with enteropathies correlates with flares of the disease. The mean duration of chronic ulcerative colitis before the onset of erythema nodosum is 5 years, and erythema nodosum is controlled with adequate therapy of the colitis. Erythema nodosum is the most frequent dermatologic symptom in inflammatory bowel diseases, and it is strongly associated with Crohn disease. [11, 12]Hodgkin disease and lymphomaErythema nodosum associated with non-Hodgkin lymphoma may precede the diagnosis of lymphoma by months. Reports of erythema nodosum preceding the onset of acute myelogenous leukemia have been published. [13, 14]SarcoidosisApproximately 10-22% of all erythema nodosum cases are caused by sarcoidosis. [15] The most common cutaneous manifestation of sarcoidosis is erythema nodosum. [16] A characteristic form of acute sarcoidosis involves the association of erythema nodosum, hilar lymphadenopathy, fever, arthritis, and uveitis, which has been termed Löfgren syndrome. This presentation has a good prognosis, with complete resolution within several months in most patients. HLA-DRB1*03 is associated with Löfgren syndrome. Most DRB1*03-positive patients have resolution of their symptoms within 2 years; however, nearly half of DRB1*03-negative patients have an unremitting course. [17]Behçet diseaseThis condition is associated with erythema nodosum.PregnancySome patients develop erythema nodosum during pregnancy, most frequently during the second trimester. Repeated episodes occur with subsequent pregnancies or with the use of oral contraceptives.EpidemiologyFrequencyUnited StatesPeak incidence occurs at age 18-34 years. Age and sex distributions vary according to etiology and geographic location. [18]InternationalRates of erythema nodosum vary according to country. In England, the rate is 2.4 cases per 10,000 per year.SexWomen are affected more often than men, with a male-to-female ratio of 1:4.AgeErythema nodosum may occur in children and in patients older than 70 years, but it is more common in young adults aged 18-34 years. Age distribution varies with geographic location and etiology.PrognosisIn patients with erythema nodosum, the prognosis is excellent. In most patients, erythema nodosum resolves without any adverse reactions.Patient EducationInstruct patients that the restriction of physical activities may help shorten the course of erythema nodosum.eMedicine LogoClinical PresentationSECTIONSErythema NodosumOverviewBackgroundPathophysiologyEtiologyEpidemiologyPrognosisPatient EducationPresentationDDxWorkupTreatmentMedicationQuestions & AnswersReferencesWhat to Read Next on MedscapeRelated Conditions and DiseasesSubacute Nodular Migratory Panniculitis (Vilanova Disease)Dermatologic Manifestations of CoccidioidomycosisFast Five Quiz: Can You Properly Identify Ulcerative Colitis and Initiate Best Treatment?Erythema Induratum (Nodular Vasculitis)Pseudotuberculosis (Yersinia pseudotuberculosis Infection)Dermatologic Manifestations of SarcoidosisNEWS & PERSPECTIVE Minocycline Effective for Erythema Nodosum LeprosumErythema Nodosum as a Result of Estrogen Patch Therapy for Prostate Cancer: A Case ReportEtiology and Therapeutic Management of Erythema Nodosum During PregnancyTOOLSDrug Interaction CheckerPill IdentifierCalculatorsFormularySLIDESHOW Cutaneous Signs of 10 Unusual Systemic DiseasesMost Popular ArticlesAccording to Dermatologists Behind the Pimple Video Craze Coffee May Reduce Rosacea Risk FDA Approves Sarecycline for Moderate to Severe Acne Dysplastic Nevi: Monitoring and Management Chronic Pruritus: A Review of Neurophysiology and Associated Immune Neuromodulatory TreatmentsView More Medscape LogoFIND US ON ABOUTAbout MedscapePrivacy PolicyCookiesTerms of UseAdvertising PolicyHelp CenterMEMBERSHIPEmail NewslettersManage My AccountAPPSMedscapeMedPulse NewsCME & EducationWEBMD NETWORKWebMDMedicineNeteMedicineHealthRxListWebMD CorporateEDITIONSEnglishDeutschEspañolFrançaisPortuguêsAll material on this website is protected by copyright, Copyright © 1994-2019 by WebMD LLC. 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