Erythema nodosum L52.0

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 24.05.2021

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Synonym(s)

dermatitis contusiformis; erythema contusiforme; Knotted Rose; Node erythema; Tuberkulid nodose

History
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Willan, 1798; Hebra, 1860

Definition
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Acute, usually infection-related (frequently streptococcal infections), self-limiting panniculitis associated with general symptoms such as fever and arthralgias as well as subcutaneous, painful nodules (predominantly) on the extensor sides of the lower legs.

Occurrence/Epidemiology
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Panethnic. Most common septal panniculitis. Prevalence in Central Europe: 100-200/100.000 inhabitants/year. Incidence in Central Europe: 2-8/100,000 inhabitants/year.

Etiopathogenesis
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In a larger proportion of cases (30-50%), an exact assignment to a triggering cause is not possible. In addition to these "idiopathic" cases, infectious and/or drug-allergic causes or combinations thereof can be detected. The spectrum of infections is very different in the various regions of the world. World regions very different.

Manifestation
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Mostly occurring in adults between the ages of 20 and 40. Also occurring in children and adolescents.

f:m=3-6:1

Seasonally clustered in spring and autumn.

Localization
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Lower leg extension sides, also thighs and arms.

Clinical features
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Beginning with general symptoms such as fever, fatigue, tiredness, rheumatoid pain as well as symmetrically and bilaterally arranged, light or bright red, blurred, 2.0-10.0 cm in size, pressure pain, sometimes extremely pressure pain (so that even light touching is felt as unpleasant), doughy, slightly raised, reddish-livid lumps or plaques with a smooth, taut surface. The skin changes can confluent to larger (up to 5-15 cm) areas. The nodules never ulcerate. The single foci heal within 3-6 weeks with a change of colour (from reddish-brown to reddish-brown to brown-yellow and a slight grey-yellow) without scarring. In the eruption phase fresh spurts can occur.

Rare is a migratory centrifugal expansion of the foci, an activity state also known as subacute migratory panniculitis (panniculitis subacuta nodularis migrans) or erythema nodosum migrans.

Laboratory
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BSG significantly accelerated; leukocytosis; pathologies in the context of the underlying disease (e.g. CRP; antistreptolysintiter; Yersinia serology).

Histology
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Initial: infiltration by neutrophil granulocytes in the adipose tissue septum, formation of Miescher's radial nodules; edema, macrophages, foam cells.

Full-stage: granulomatous reaction of the adipose tissue; non-specific concomitant reaction in the reticular dermis; adipose tissue septums are fibrotically transformed.

Differential diagnosis
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Erythema induratum: chronic persistent, infectious allergic lobular panniculitis combined with vasculitis of the small vessels of the fat lobules. The dorsal parts of the lower leg are affected. The delimitation as an independent entity is still controversial!

Polyarteritis nodosa cutanea: Painful nodules and plaques: often onset with recurrent vasculitic plaques or nodules (iceberg phenomenon), 1.0 - 5.0 cm in size, rough, usually very pressure-dolent, also spontaneously painful, reddish to livid in colour. Not infrequently painful ulcers (60%).

Syphilitic gummata: Rare; serologic evidence of syphilis.

Nodular medicinal erythema: Exanthematous seeding of nodular erythema. Anamnestic relationship to drug administration.

Pernio:Acral localization of inflammation. Anamnestically clear dependence of the symptomatology on cold influences.

Cold panniculitis: Localized inflammation of the subcutaneous adipose tissue, in the wake of external influences such as cold or wetness. Typically, 2 to 3 days (rarely delayed to 10-14 days) after local hypothermia, deeply cutaneous, succulent, painful nodules appear in the adipose tissue. Classically in riders on the extensor sides of the thighs.

Pancreatic panniculitis: in lipase-producing eccrine pancreatic carcinoma or also in acute or chronic (often alcohol-induced) pancreatitis.

Nodular erythema in Behcet's disease: probably identical with classic erythema nodosum.

Therapy
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Clarification and treatment of the underlying disease. In severe cases bed rest.

External therapy
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Creams containing glucocorticoids such as 0.1% triamcinolone cream(e.g. Triamgalen, R259 ) or highly potent glucocorticoids such as clobetasol (e.g. Dermoxin cream), if necessary under occlusion. Moist compresses with NaCl, followed by consistent compression therapy (Pütter bandages after arterial Doppler) until complete healing.

Internal therapy
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Acetylsalicylic acid (e.g. aspirin) 2-3 g/day p.o. In severe cases glucocorticoids such as prednisolone (e.g. Decortin H) 60-80 mg/day p.o. or i.v.Recently recommendations of potassium iodide 300-1500 mg/day for a few days to 8 weeks in Crohn's disease associated, therapy refractory erythema nodosum.

Progression/forecast
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Cheap. Spontaneous healing. Total duration: 3-6 weeks. Recurrence possible.

Literature
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  1. Aydın-Teke T et al (2014) Erythema nodosum in children: evaluation of 39 patients. Turk J Pediatr 56:144-149
  2. Blake T et al (2014) Erythema nodosum - a review of an uncommon panniculitis. Dermatol Online J 20: 22376
  3. Hebra F (1860) Diseases of the Skin. vol 1 (London) New Sydenham Society
  4. Marcoval J et al (2003) Papular sarcoidosis of the knees: a clue for the diagnosis of erythema nodosum-associated sarcoidosis. J Am Acad Dermatol 49: 75-78
  5. Okafor MC (2003) Thalidomide for erythema nodosum leprosum and other applications. Pharmacotherapy 23: 481-493
  6. Requena L et al (2002) Erythema nodosum. Dermatol Online J 8:4
  7. Foti C et al. (2001) Tinea barbae associated with erythema nodosum in an immunocompetent man. J Eur Acad Dermatol Venereol 15: 250-251
  8. Ishimatsu Y et al (2014) A Japanese patient with Löfgren's syndrome with an HLA-DR12 allele and review of literature on Japanese patients. Tohoku J Exp Med 234:137-141
  9. Kwok T et al (2014) Sweet syndrome with panniculitis, arthralgia, episcleritis, and neurologic involvement precipitated by antibiotics. Dermatol Online J 20 pii: 13030/qt9tm147p2
  10. Litwin L et al (2014) The etiology and clinical manifestation of erythema nodosum in hospitalized children - analysis of 12 cases. Preliminary report. Dev Period Med 18: 506-512
  11. Willan R (1798) On Cutaneous Diseases. vol 1 (London) J. Johnson, St Paul's Church-Yard

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Last updated on: 24.05.2021