Friday, April 25, 2008
ERYTHEMAErythema Nodosum
Medical Author: William C. Shiel Jr., MD, FACP, FACR
What is erythema nodosum?
What causes erythema nodosum?
How is erythema nodosum diagnosed?
How is erythema nodosum treated?
What is erythema nodosum?
Erythema nodosum is a type of skin inflammation that is located in a certain portion of the fatty layer of skin. Erythema nodosum (also called EN) results in reddish, painful, tender lumps most commonly located in the front of the legs below the knees. The tender lumps, or nodules, of erythema nodosum range in size from 1 to 5 centimeters. The nodular swelling is caused by a special pattern of inflammation in the fatty layer of skin.
Erythema nodosum can be self-limited and resolve on its own in three to six weeks. Upon resolution, it may leave only a temporary bruised appearance or leave a chronic indentation in the skin where the fatty layer has been injured.
There are several scenarios for the outcome of erythema nodosum. Typically, these areas of nodular tenderness range in size from about a dime to a quarter and they may be tender and inflamed off and on for a period of weeks. They usually then resolve spontaneously, each one of the little areas of inflammation shrinking down and then becoming flat rather than raised and inflamed. They leave a bruised appearance. Then, they resolve spontaneously completely. Other lesions can sometimes pop up elsewhere. This may occur for periods of weeks to months and then eventually goes away. However, chronic erythema nodosum that may last for years is another pattern. Chronic erythema nodosum, with intermittent recurrences, can occur with or without an underlying disease present.
What causes erythema nodosum?
Erythema nodosum may occur as an isolated condition or in association with other conditions. Conditions that are associated with erythema nodosum include medications (sulfa-related drugs, birth control pills, estrogens), strep throat, Cat scratch disease, fungal diseases, infectious mononucleosis, sarcoidosis, Behcet's disease, inflammatory bowel diseases (Crohn's disease and ulcerative colitis), and normal pregnancy.
How is erythema nodosum diagnosed?
Usually, erythema nodosum is a straightforward, simple diagnosis for a doctor to make simply by examining a patient and noting the typical firm area of raised tenderness that is red along with areas which have had lesions resolved, which might show a bruised-like appearance. It is not a difficult diagnosis for an experienced doctor. It does not typically require other investigative tests.
Sometimes a biopsy is done for confirmation, for example, if a patient presented with an isolated, singular area and a doctor was unable to make a diagnosis based on its appearance. The biopsy of the deeper layers of tissue of skin can prove that it is erythema nodosum. Those layers would show the specific fatty layers of inflammation.
How is erythema nodosum treated?
Erythema nodosum is initially managed by identifying and treating any underlying condition present. Simultaneously, treatment is directed toward the inflamed skin from the erythema nodosum.
Treatments for erythema nodosum include antiinflammatory drugs, and cortisone by mouth or injection. Colchicine is sometime used effectively to reduce inflammation. Treatment must be customized for the particular patient and conditions present. It is important to note that erythema nodosum, while annoying and often painful, does not threaten internal organs and the long-term outlook is generally very good.
References: Clinical Primer of Rheumatology, Lippincott Williams & Wilkens, edited by William Koopman, et al., 2003.
Kelley's Textbook of Rheumatology, W B Saunders Co, edited by Shaun Ruddy, et al., 2000.
Erythema
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Erythema
Classification and external resources
ICD-10 L51.-L54.
ICD-9 695
DiseasesDB 4466
MeSH D004890
Erythema is redness of the skin caused by capillary congestion.
It can be caused by infection, massage, electrical treatments, acne medication, allergies, exercise or solar radiation (sunburn), and waxing and plucking of the hairs any of which can cause the capillaries to dilate, resulting in redness. Erythema is a common side effect of radiotherapy treatment due to patient exposure to ionizing radiation.
[edit] Associated conditions
Erythema ab igne
Erythema induratum
Erythema infectiosum (or fifth disease)
Erythema marginatum
Erythema migrans
Erythema multiforme (EM)
Erythema nodosum
Erythema toxicum
Palmar erythema
In about 30-50% of cases, the cause of Erythema is unknown.
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.
Contents [hide]
1 Clinical manifestations
2 Diagnosis
3 Epidemiology
4 Causes
5 Treatment
6 External links
7 References
[edit] 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 [1][2]. 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 [3][4]. 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[5].
Dermatophytids are similar skin lesions that result from a fungus infection such as ringworm in another area of the body.
[edit] 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[5].
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 (ASO) titer, urinalysis, throat culture, intradermal tuberculin test, and chest x-ray is part of the initial examination.[6]
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. 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).
[edit] 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[5].
[edit] Causes
In about 30-50% of cases, the cause of EN is unknown.[7] 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.[7][8][9][10]
[edit] 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).[5] NSAIDS are usually more effective at the onset of EN versus with chronic disease.
Potassium iodide can be used for persistent lesions whose cause remains unknown. Corticosteroids and colchicine can be used in severe refractory cases (Yurdakul et al, 2001).[11][12][13]
[edit] External links
[1] Erythema Nodosum information
[edit] References
^ Ryan TJ (1998). "Cutaneous vasculitis", in Burns DA, Breathnach SM: Textbook of Dermatology, 6th ed., London: Blackwell Science Ltd, 2155-225. ISBN 0-632-05064-0.
^ Camilleri MJ, Su WPD (2003). "Panniculitis", in Freedberg IM, Eisen AZ, Wolff K, Austen KF, Goldsmith LA, Katz SI: Fitzpatrick's Dermatology In General Medicine, 6th ed., New York, NY: McGraw-Hill. ISBN 0-07-138076-0.
^ Cribier B, Caille A, Heid E, Grosshans E (1998). "Erythema nodosum and associated diseases. A study of 129 cases". Int J Dermatol 37 (9): 667-72. PMID 9762816.
^ White WL, Hitchcock MG (1999). "Diagnosis: erythema nodosum or not?". Semin Cutan Med Surg 18 (1): 47-55. PMID 10188842.
^ a b c d Wolff K, Johnson RA, Suurmond R (2005). "Section 7: Miscellaneous inflammatory disorders", Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology, 5th ed., New York, NY: McGraw-Hill Professional. ISBN 0-07-144019-4.
^ Garcia-Porrua C, Gonzalez-Gay MA, Vazquez-Caruncho M, Lopez-Lazaro L, Lueiro M, Fernandez ML, Alvarez-Ferreira J, Pujol RM (2000). "Erythema nodosum: etiologic and predictive factors in a defined population". Arthritis Rheum 43 (3): 584-92. PMID 10728752.
^ a b Mert A, Ozaras R, Tabak F, Pekmezci S, Demirkesen C, Ozturk R (2004). "Erythema nodosum: an experience of 10 years". Scand J Infect Dis 36 (6-7): 424-7. PMID 15307561.
^ Anan T, Imamura T, Yokoyama S, Fujiwara S (2004). "Erythema nodosum and granulomatous lesions preceding acute myelomonocytic leukemia". J Dermatol 31 (9): 741-7. PMID 15628321.
^ Bohn S, Buchner S, Itin P (1997). "[Erythema nodosum: 112 cases. Epidemiology, clinical aspects and histopathology]". Schweiz Med Wochenschr 127 (27-28): 1168-76. PMID 9324739.
^ Lin JT, Chen PM, Huang DF, Kwang WK, Lo K, Wang WS (2004). "Erythema nodosum associated with carcinoid tumour". Clin Exp Dermatol 29 (4): 426-7. PMID 15245549.
^ Mat C, Yurdakul S, Uysal S, Gogus F, Ozyazgan Y, Uysal O, Fresko I, Yazici H (2005). "A double-blind trial of depot corticosteroids in Behcet's syndrome". Rheumatology (Oxford). PMID 16263779.
^ Wallace SL (1967). "Erythema nodosum treatment with colchicine". JAMA 202 (11): 1056. PMID 6072607.
^ Yurdakul S, Mat C, Tuzun Y, Ozyazgan Y, Hamuryudan V, Uysal O, Senocak M, Yazici H (2001). "A double-blind trial of colchicine in Behcet's syndrome". Arthritis Rheum 44 (11): 2686-92. PMID 11710724.
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