Erythema Nodosum UCSF Dermatology Last updated 10.25.10 Modules Instructions  The following module contains a number of green, underlined terms which are hyperlinked to the dermatology glossary, an illustrated interactive guide to clinical dermatology and dermatopathology.  We encourage the learner to read all the hyperlinked information. Goals and Objectives  The purpose of this module is to help medical students develop a clinical approach to the evaluation and initial management of patients presenting with erythema nodosum.  After completing this module, the medical student will be able to: • Identify and describe the morphology of erythema nodosum • Name conditions associated with erythema nodosum • Describe treatment options, including supportive care for erythema nodosum • Discuss when to refer to a dermatologist Case One Mrs. Cheryl Mosely Case One: History  HPI: Mrs. Mosely is a 35 year-old woman who presents to her primary care physician with tender red “bumps” on her anterior shins. The lesions appeared over the course of a few days and have started to resolve with faint bruises remaining. She also reports a recent history of a sore throat and fever two weeks ago, which improved after a course of antibiotics.  PMH: no major illness or hospitalizations  Meds: none  All: none  FH: not-contributory  SH: lives with husband and 12 year-old child who also had a sore throat  Health-related behaviors: no tobacco, alcohol or drug use  ROS: no cough or rhinorrhea Case One: Exam Vital signs: normal Gen: well-appearing HEENT: normal Skin: multiple scattered shiny, red nodules on the anterior shins bilaterally Case One, Question 1  What is the appropriate next step? a. b. c. d. Biopsy the lesion Drain the nodules Anti-Streptolysin O titer Topical steroid ointment Case One, Question 1 Answer: c  What is the appropriate next step? a. Biopsy the lesion (diagnosis can be made clinically) b. Drain the nodules (lesions are more inflammatory vs. abscess) c. Anti-Streptolysin O titer d. Topical steroid (not effective) Diagnosis: Erythema Nodosum  Mrs. Mosely’s recent history of sore throat and fever is suggestive of acute pharyngitis. Her ASO titer came back elevated.  The lesions on her legs were diagnosed as Erythema Nodosum Erythema Nodosum: The Basics  Erythema nodosum is characterized by the presence of round, raised, non-ulcerative painful red nodules • Often symmetric distribution, located bilaterally below the knees (mainly on the anterior tibial surface) • Lesions evolve from bright red to brown-yellow, resembling old ecchymoses • Old and new lesions often coexist • Patients may also present with fever, fatigue, and arthralgias  The morphology of the lesion, a deep nodule, identifies EN as an inflammatory disease of the fat (called a panniculitis) Case One, Question 2  Which of the following history and clinical items are commonly found in patients with EN? a. b. c. d. e. Recent fever Patient is female Recent upper respiratory infection Use of oral contraceptives All of the above Case One, Question 2 Answer: e  Which of the following history and clinical items are commonly found in patients with EN? a. b. c. d. e. Recent fever Patient is female Recent upper respiratory infection Use of oral contraceptives All of the above Erythema Nodosum: The Basics  Can occur at any age, but most cases appear between 2nd and 4th decades  15-20x more common in women than men  EN is not a disease, but a reaction pattern to a variety of factors including infections, medications, and systemic diseases Erythema Nodosum: The Basics  Diagnosis of EN should always be followed by a search for the underlying etiology  Streptococcal disease is the most common cause of EN in children  Drugs, sarcoidosis, and inflammatory bowel disease (IBD) are commonly associated disorders in adults with EN Conditions Associated with EN  Idiopathic > 50%  Infections • Streptococcal infections, tuberculosis, histoplasmosis, coccidiomycosis  Drugs • Oral contraceptive pills, Sulfonamides  Neoplasms • Lymphoma, leukemia, renal cell carcinoma  Miscellaneous Conditions • Sarcoidosis, inflammatory bowel disease Note: Only a few common causes of EN are mentioned. EN is associated with a wide variety of disease processes and medications. Case One, Question 3  Which of the following statement regarding treatment of EN is true? a. b. c. d. EN tends to be self-limited Antihistamines are often used for treatment Anti-inflammatories should be avoided Systemic steroids are of no value Case One, Question 3 Answer: a  Which of the following statement regarding treatment of EN is true? a. EN tends to be self-limited b. Antihistamines are often used for treatment (not true) c. Anti-inflammatories should be avoided (not true. Antiinflammatories are often used in the treatment of EN) d. Systemic steroids are of no value (not true. Systemic steroids can be used if underlying infection and malignancy have been excluded) Erythema Nodosum: Treatment  EN is usually self-limited or resolves with treatment of the underlying disorder • Lesions heal without atrophy or scarring • Eruption generally lasts from 3 to 6 weeks, and recurrences are frequent  Treatment is typically symptomatic • Supportive measures and pain control are recommended  The use of systemic glucocorticoids should be weighed against the possibility of masking an underlying neoplastic, inflammatory, or infectious condition  Oral potassium iodide therapy is another treatment option Case Two Ms. Beverly Prescott Case Two: History  HPI: Ms. Prescott is a 35 year-old woman who presents to her primary care provider with tender red nodules on her anterior shins. Some of the lesions appear to be resolving, but others are still appearing. No sick contacts or anyone else with a rash.  PMH: no major illnesses or hospitalizations  All: none  Meds: oral contraceptive pills (unable to recall the name)  FH: father with history of BCC, otherwise not-contributory  SH: lives with a friend in an apartment, works in advertising  Health-related behaviors: alcohol use (1-2 drinks per week), no tobacco or drug use  ROS: feeling well, no signs and symptoms of illness Case Two: Exam Vital Signs: normal HEENT: normal exam Lungs: clear to auscultation Skin: multiple scattered shiny, red nodules on the anterior lower extremities Case Two, Question 1  The primary care provider suspects erythema nodosum. What else should be considered as part of the initial evaluation? a. Make sure a thorough medical history and review of systems was performed b. Place a PPD c. Order ASO d. All of the above Case Two, Question 1 Answer: d  The primary care provider suspects erythema nodosum. What else should be considered as part of the initial evaluation? a. Make sure a thorough medical history and review of systems was performed b. Place a PPD c. Order an ASO d. All of the above Case Two, Question 2  What is the likely cause of the Ms Prescott’s erythema nodosum? a. b. c. d. Sarcoidosis Oral contraceptives Tuberculosis Crohn’s disease Case Two, Question 2 Answer: b  What is the likely cause of the Ms Prescott’s erythema nodosum? a. Sarcoidosis (possible, but less likely) b. Oral contraceptives c. Tuberculosis (no known risk factors, but a PPD placement would be prudent) d. Crohn’s disease (possible that EN is the presenting feature of IBD, but her OCP use is a more likely cause in this case) Case Three Ms. Maria Ojeda Case Three: History  HPI: Ms. Ojeda is a 50 year-old woman who presents to the general medicine clinic with tender red nodules on her posterior calves for the past 2 months.  PMH: last visit to doctor 10 years ago, no major illnesses or hospitalizations  Medications: none  Allergies: none  Family history: mother with hypertension  Social history: lives with multiple family members in the city, recently moved to US from Guatemala  Health-related behaviors: no tobacco, alcohol or drug use  ROS: feels well, occasionally tired Case Three: Exam Vital signs and physical exam normal except for: tender erythematous shiny nodules on the posterior calves bilaterally Case Three, Question 1  What is the most likely diagnosis? a. b. c. d. Erythema nodosum Erythema induratum Syphilitic gumma None of the above Case Three, Question 1 Answer: b  What is the most likely diagnosis? a. Erythema nodosum (characterized by the presence of round, raised, non-ulcerative painful red nodules) b. Erythema induratum c. Syphilitic gumma (painless subcutaneous nodules, enlarge, attach to the overlying skin, and eventually ulcerate) d. none of the above Erythema Induratum  Erythema induratum is a panniculitis characterized by tender subcutaneous nodules usually located on the lower posterior calf  Erythema induratum is chronic and occurs mostly in middle-aged women  Occurs in the setting of tuberculosis (latent) • PPD will usually be positive  Lesions can resolve spontaneously with or without ulceration and often heal with scaring When to Biopsy Panniculitis  For persistent lesions (> 6wks) or when the diagnosis is unclear a biopsy is typically necessary and these patients should be referred to a dermatologist  A deep incisional or excisional biopsy should be obtained for best visualization because a punch biopsy is likely to produce an inadequate sample Take Home Points  EN is characterized by round, raised, nonulcerative painful red nodules on the skin and subcutaneous fat  Most cases appear between the 2nd and 4th decade of life and is more common in women  There are numerous etiologies for EN including infections, medications, neoplasms and other miscellaneous conditions  Streptococcal disease is the most common etiologic factor in children Take Home Points  Drugs, sarcoidosis, systemic fungal infections (coccidiomycosis, histoplasmosis) and inflammatory bowel disease are commonly associated disorders in adults with EN  EN tends to be self-limited or resolves with treatment of the underlying disorder  Erythema induratum can be distinguished from EN by the chronic time course, location on the posterior calf, ulceration of the lesions and association with latent tuberculosis End of the Module  Wolff K, Johnson RA, "Section 7. Miscellaneous Inflammatory Disorders" (Chapter). Wolff K, Johnson RA: Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology, 6e: http://www.accessmedicine.com/content.aspx?aID=5201183.  Bolognia Jean L, Braverman Irwin M, "Chapter 54. Skin Manifestations of Internal Disease" (Chapter). Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, Loscalzo J: Harrison's Principles of Internal Medicine, 17e: http://www.accessmedicine.com/content.aspx?aID=2864525.  James WD, Berger TG, Elston DM, “Chapter 23. Diseases of Subcutaneous Fat” (chapter). Andrews’ Diseases of the Skin Clinical Dermatology. 10th ed. Philadelphia, Pa: Saunders Elsevier; 2006: 487-489.  James WD, Berger TG, Elston DM, “Chapter 16. Mycobacterial Disease” (chapter). Andrews’ Diseases of the Skin Clinical Dermatology. 10th ed. Philadelphia, Pa: Saunders Elsevier; 2006: 337.  Requena L, Yuz ES. Erythema Nodosum. Semin Cutan Med Surg. 2007;26:114125. Requena Luis, Yus Evaristo S, Kutzner Heinz, "Chapter 68. Panniculitis" (Chapter). Wolff K, Goldsmith LA, Katz SI, Gilchrest B, Paller AS, Leffell DJ: Fitzpatrick's Dermatology in General Medicine, 7e: http://www.accessmedicine.com/content.aspx?aID=2978288.  Schwartz RA, Nervi SJ. Erythema Nodosum: A Sign of Systemic Disease. Am Fam Physician. 2007;75:695-700.