Erythema Nodosum

The usual erythema nodosum phenotype is acute tender erythematous-to-violaceous subcutaneous nodules, predominantly on the pretibial legs. Fever, arthralgia, and ankle-predominant joint symptoms can accompany the eruption and do not independently establish a specific cause. JAMA+2JAMASweet's Syndrome and Erythema Nodosum - JAMA NetworkScienceDirectErythema Nodosum - an overviewScienceDirectErythema Nodosum - an overview | ScienceDirect Topics

Do not assume that every painful leg nodule is erythema nodosum. Ulceration, drainage, marked asymmetry, fixed plaque-like lesions, neuropathy, widespread papules or pustules, or a prolonged relapsing course should prompt reassessment for other inflammatory, infectious, malignant, or leprosy-associated nodular disorders. Erythema nodosum leprosum, for example, may occur with nodules plus ulcers, sensory loss, systemic inflammation, cytopenias, or hepatosplenomegaly. Wolters Kluwer+1Wolters KluwerAbstracts : Journal of Clinical Infectious Disease Society - OvidScienceDirectErythema Nodosum Leprosum - an overview

Perform a biopsy when morphology is atypical or the diagnosis will alter treatment. Sample sufficient subcutaneous tissue, because erythema nodosum is a panniculitis involving subcutaneous adipose tissue; a superficial specimen can miss the diagnostic compartment. BMJ+2BMJRash on the arms and legs - The BMJOxford AcademicLeptospirosis presented with erythema nodosum on four limbsWileyEarly Primary Biliary Cirrhosis: A New Association with Erythema ...

A focused initial evaluation should include review of recent pharyngitis, respiratory illness, diarrhea, tuberculosis exposure, travel or residence in fungal-endemic regions, pregnancy, medication changes, and symptoms of bowel, ocular, or mucosal inflammatory disease. Major associated categories include poststreptococcal infection, tuberculosis, deep fungal infection, sarcoidosis, inflammatory bowel disease, Yersinia enterocolitis, pregnancy, drugs, and idiopathic disease. ScienceDirect+1ScienceDirectErythema Nodosum - an overviewScienceDirectErythema Nodosum - an overview | ScienceDirect Topics

Obtain a chest radiograph as part of the etiologic evaluation, particularly when cough, dyspnea, constitutional symptoms, tuberculosis risk, or sarcoidosis features are present. Chest imaging may identify early pulmonary findings of tuberculosis, sarcoidosis, or deep fungal infection. ScienceDirectScienceDirectErythema Nodosum Leprosum - an overview Add tuberculosis testing when epidemiology or chest findings raise concern; a purified protein derivative test is specifically described as an assessment option. ScienceDirectScienceDirectErythema Nodosum Leprosum - an overview

For recent or current pharyngitis, obtain throat culture and assess for evidence of recent streptococcal infection with anti-DNase B testing. The cutaneous eruption may follow pharyngitis by approximately 3 weeks, so a resolved sore throat does not exclude this branch. ScienceDirect+1ScienceDirectErythema Nodosum Leprosum - an overviewScienceDirectErythema Nodosum - an overview | ScienceDirect Topics For diarrheal disease, prioritize stool-directed evaluation for enteric infection, including Yersinia, while persistent diarrhea, abdominal pain, weight loss, or hematochezia should shift the workup toward inflammatory bowel disease. ScienceDirect+1ScienceDirectErythema Nodosum - an overviewScienceDirectErythema Nodosum - an overview | ScienceDirect Topics

In established inflammatory bowel disease, erythema nodosum is a recognized dermatologic extraintestinal manifestation and appears to mirror underlying bowel activity. NEJM+1NEJMErythema Nodosum and Pyoderma Gangrenosum in Inflammatory Bowel Disease | NEJM ClinicianWolters KluwerACG Clinical Guideline: Management of Crohn's Disease in Adults New gastrointestinal symptoms in a patient with erythema nodosum should therefore prompt bowel-directed assessment rather than repeated empiric treatment of skin nodules alone. In one IBD disease-activity framework, active disease thresholds were C-reactive protein greater than 5 mg/L, erythrocyte sedimentation rate greater than 30 mm/hour, and fecal calprotectin greater than 250 micrograms/g. Oxford AcademicOxford AcademicErythema nodosum as a marker for objective disease activity in ...

For active Crohn disease with erythema nodosum, coordinate treatment with the IBD team and avoid allowing symptom relief from corticosteroids to substitute for control of intestinal inflammation. ACG guidance emphasizes sparing use of corticosteroids in Crohn disease, gradual discontinuation once begun, and addition of steroid-sparing therapy when needed; corticosteroids are relatively contraindicated in perforating complications such as abscess or fistula. Wolters KluwerWolters KluwerACG Clinical Guideline: Management of Crohn's Disease in Adults

Erythema nodosum is the most common nonspecific cutaneous lesion of sarcoidosis and may occur in up to 25% of sarcoidosis cases. ScienceDirectScienceDirectErythema Nodosum - an overview A chest radiograph is the first practical discriminator in patients with respiratory symptoms, hilar or pulmonary suspicion, or no alternate trigger. ScienceDirectScienceDirectErythema Nodosum Leprosum - an overview Erythema nodosum associated with acute sarcoidosis has been linked to a high spontaneous remission rate, but pulmonary and other organ assessment should be guided by the chest findings and symptoms. ScienceDirectScienceDirectErythema Nodosum - an overview

Behçet disease should be considered when erythema nodosum-like lesions occur with recurrent oral aphthosis, genital aphthosis, eye disease, acneiform lesions, or pathergy. Under the 2014 International Criteria for Behçet's Disease, oral, genital, and ocular lesions each contribute diagnostic points, while skin lesions and pathergy contribute additional points. Ocular inflammation can include anterior uveitis, posterior uveitis, panuveitis, and retinal vasculitis with risk of irreversible vision loss; urgent ophthalmologic assessment is required for visual symptoms or red eye. BMJBMJNeurological involvement by Behçet’s syndrome: clinical features, diagnosis, treatment and outcome | Practical Neurology

Management begins with identifying and removing or treating the precipitating condition: evaluate and manage confirmed streptococcal, enteric, mycobacterial, or fungal infection; discontinue a plausible medication trigger when feasible; and treat the associated inflammatory disorder when present. Erythema nodosum is a hypersensitivity reaction pattern associated with infections, inflammatory bowel disease, medications, pregnancy, sarcoidosis, and systemic inflammatory disease. ScienceDirect+1ScienceDirectErythema Nodosum - an overviewScienceDirectErythema Nodosum - an overview | ScienceDirect Topics

For patients with Crohn disease, skin improvement should be interpreted alongside intestinal activity and complications. Corticosteroids should be used sparingly, tapered gradually once started, and not relied upon as durable maintenance therapy; concern for abscess or fistula is a major reason to avoid or defer corticosteroids until perforating complications are addressed. Wolters KluwerWolters KluwerACG Clinical Guideline: Management of Crohn's Disease in Adults

Reassess the diagnosis and repeat directed systemic evaluation when nodules recur without an identified trigger, fail to follow the expected inflammatory course, or develop atypical features. The etiologic spectrum includes infections, drugs, autoimmune and inflammatory disease, lymphoreticular malignancy, and other systemic disorders; recurrence should reopen the differential rather than automatically be labeled idiopathic. ScienceDirect+2ScienceDirectErythema Nodosum Leprosum - an overviewScienceDirectErythema Nodosum - an overview | ScienceDirect TopicsScienceDirectRecurrent Panniculitis in a Man With Asthma Receiving Treatment With Leukotriene-Modifying Agents - ScienceDirect