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Great Ormond Street Hospital for Children NHS Foundation Trust: Information for Families Erythema nodosum This information sheet from Great Ormond Street Hospital explains the causes, symptoms and treatment of erythema nodosum and where to get help. Erythema nodosum is a dermatological (skin) condition. It is a type of panniculitis. Panniculitis is the name for inflammation of the layer of fat lying underneath the skin. It causes red nodules (rounded lumps) to form just below the skin surface, usually on the shins. In most people, there is no obvious reason or cause for erythema nodosum to occur. and inside the throat. This is the most common trigger for erythema nodosum in children. What causes erythema nodosum? There are also other infections which can trigger this condition. In most people, there is no obvious reason or cause for erythema nodosum to occur. Doctors call this idiopathic erythema nodosum (as idiopathic means of unknown cause). However, in some people a trigger can be identified. The most common trigger for this skin condition is a streptococcal infection or sarcoidosis. Streptococcal infections are any type of infection caused by a type of bacteria called streptococcus or ‘strep’ for short. Strep infections can vary in severity from mild throat infections to pneumonia. Sheet 1 of 3 Sarcoidosis is a disease of unknown cause that leads to inflammation which causes tiny lumps of cells to form in various organs in the body, most commonly in the lungs and lymph glands. The lumps are called granulomas. Sarcoidosis is a common trigger for erythema nodosum in adults. Tuberculosis (TB) can trigger erythema nodosum. This is a bacterial infection that usually affects the lungs. Infections such as chlamydia (a disease caused by bacteria which is most commonly sexually transmitted), mycoplasma pneumoniae (a type of atypical pneumonia which can affect younger people), yersinia enterocolitica (a bacterial infection that causes diarrhoea and abdominal pain), salmonella (a foodborne illness caused by bacteria) and campylobacter (another foodbourne infection) are other, less common, triggers. There are more than 20 different types of strep bacteria but one group is called group A strep (strep A), which are often found on the surface of the skin A reaction to certain drugs may trigger erythema nodosum in some people. For example, reactions to some antibiotics or Ref: 2012F1224 © GOSH NHS Foundation Trust April 2012 the combined oral contraceptive pill. People with an inflammatory bowel condition such as ulcerative colitis and Crohn’s disease may also develop this condition and pregnancy can also trigger erythema nodosum. Certain cancers including lymphoma and leukaemia can also be triggers. In cases where a trigger can be found, it is thought that erythema nodosum is caused by the immune system becoming hypersensitive (or over-reacting) to the trigger. Sometimes erythema nodosum may be the first sign of the serious underlying condition that needs to be identified and treated. Erythema nodosum is rare. It affects between two and three people in every 10,000 people per year in the UK. It is most common between the ages of 20 and 35 but it can occur at any age. What are the signs and symptoms of erythema nodosum? Usually the first sign of erythema nodosum is flu-like symptoms. This happens before the nodules appear and may a child feel generally unwell for a few weeks. They may have a fever, a cough and may lose weight during this time. They may also have aching joints, stiffness and general aches and pains. Their joints may become swollen. Ankle, knee and wrist joints are most commonly affected but any joint can be painful. Aching legs and joints can last for a number of weeks, or even months, after the nodules have appeared. Sheet 2 of 3 Ref: 2012F1224 The nodules (rounded lumps) that occur in erythema nodosum can measure between two to six centimetres across. The shins are the most common site. Other common sites are on the arms, thighs and trunk but nodules can occur anywhere on the body. Each nodule tends to last for about two weeks but new nodules can continue to appear for up to six weeks. When the nodule first appears it is usually red, hot and firm to the touch. It then becomes more squashy. As the nodule begins to fade, it looks more like a bruise, turning blue and then yellowish. It usually takes some weeks for the nodules to heal completely. They do not leave any scarring. Sometimes there can be symptoms due to the underlying trigger. These depend on the trigger. For example, the nodules of erythema nodosum can appear two to three weeks after a streptococcal throat infection. How is erythema nodosum normally diagnosed? If you suspect that a child has erythema nodosum they should be taken to a GP. A doctor will usually diagnose erythema nodosum by its typical appearance. They may also refer the child to a specialist for a biopsy. During a biopsy, a small sample of tissue is taken from one of the nodules. The tissue sample is then sent to the laboratory to be examined under a microscope. If the doctor diagnoses erythema nodosum, they will usually suggest some tests to look for an underlying trigger. The tests that they suggest may depend on any other symptoms that the child may have. They may include blood tests, © GOSH NHS Foundation Trust April 2012 a swab of their throat to see if infection is present and/or a chest X-ray to look for signs of TB or sarcoidosis. The doctor may suggest a special test called a tuberculin skin test. The test involves having a small injection into the child’s arm. It is used to see if they have TB. If the child has a cough, the doctor may suggest that a sample of sputum (phlegm) be sent to the laboratory to look for TB infection. The child may be referred to a lung specialist for further investigations. Sometimes a doctor will need a stool (poo) sample which can detect infections such as salmonella and campylobacter. Children who may have underlying inflammatory bowel disease such as ulcerative colitis or Crohn’s disease, might need to have a colonoscopy (an examination of the bowel with a camera). How is erythema nodosum normally treated? The nodules of erythema nodosum tend to go away by themselves and often do not need any treatment. However if they are tender or painful treatments may include: pain in the nodules and also the joint pains. Steroids – which are sometimes used provided erythema nodosum is not thought to have been triggered by an infection or a cancer. They work by reducing inflammation. If an underlying trigger for erythema nodosum has been found, this may need to be treated. The treatment depends on the trigger. What next For most children with erythema nodosum the nodules tend to heal, with no scarring, within six to eight weeks. In some children with idiopathic erythema nodosum, nodules may last for up to six months or more. Most do not have further problems. Chronic (persistent) or recurrent erythema nodosum can occur in some children but this is rare. Notes Painkiller medication. Bedrest Wearing firm, supportive bandages or stockings on your legs. Using cool wet compresses over the nodules Taking potassium iodide – liquid taken by mouth which may help relieve the Compiled by the GOSH web team Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London WC1N 3JH www.gosh.nhs.uk Sheet 3 of 3 Ref: 2012F1224 © GOSH NHS Foundation Trust April 2012