Download Erythema Nodosum UCSF Dermatology Last updated 10.25.10

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
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