ERITEMA NODOSUM PDF

NCBI Bookshelf. Wissem Hafsi ; Talel Badri. Authors Wissem Hafsi 1 ; Talel Badri 2. These nodules are characterized by a typical histological appearance regardless of the etiology, marked by acute inflammation of the dermo-hypodermic junction and interlobular septa of the hypodermic fat, evolving without necrosis or sequelae. Erythema nodosum is an acute, or recurrent hypersensitivity reaction to a variety of antigens with a clear female predominance that may be associated with several different stimuli or pathological conditions.

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NCBI Bookshelf. Wissem Hafsi ; Talel Badri. Authors Wissem Hafsi 1 ; Talel Badri 2. These nodules are characterized by a typical histological appearance regardless of the etiology, marked by acute inflammation of the dermo-hypodermic junction and interlobular septa of the hypodermic fat, evolving without necrosis or sequelae. Erythema nodosum is an acute, or recurrent hypersensitivity reaction to a variety of antigens with a clear female predominance that may be associated with several different stimuli or pathological conditions.

Erythema nodosum can occur due to a vast number of underlying causes including but not limited to idiopathic, infectious, and a variety of noninfectious causes as outlined below.

Some pregnant patients may develop erythema nodosum during the second trimester. In addition, recurrence of the disorder may also occur with future pregnancies. EN is the most common clinical form of the acute nodular hypodermis. It occurs more often in women between 25 and 40 years, but it can be observed at any age.

Compared to men, women are affected three to six times more. It is rare without sex predominance in the pediatric population. Familial cases have been reported and are usually caused by an infectious etiology.

EN is the result of a nonspecific cutaneous reaction to various antigens. The mechanism involved would be immunologically mediated. Numerous direct and indirect evidence supports the notion of type IV delayed hypersensitivity response to many antigens.

However, this hypothesis is not accepted by all authors. Skin biopsy is not usually needed in the typical forms as a diagnosis can be reached from a detailed history and physical examination. Usual features suggestive EN include acute onset tender nodules on typical locations most commonly on shins. Skin biopsy is useless in typical forms. It highlights the involvement of interlobular septa by a lymphohistiocytic inflammatory infiltrate, sparing fat lobules and vessels.

This aspect is invariable, whatever the etiology. EN is characterized in a rather stereotyped way, whatever its cause, by the following evolutionary aspects:. The succession of outbreaks confers on the eruption of a polymorphic appearance with knots of different ages, featuring the various shades of local biligenia.

Sometimes joint swelling and morning stiffness may be present. The swelling may resolve in a few days but the pain may last for a few months. There is usually no joint destruction and the synovial fluid is sterile. The positive diagnosis of EN is primarily clinical. However, a thorough anamnesis looking for tuberculous contagion, fever, bloody diarrhea, abdominal pain, respiratory problems, dysphagia, etc. In typical cases, a complementary investigation for positive diagnostic is not necessary.

Nevertheless, it finds its place in the etiological diagnosis. Taking into account the above, the etiological assessment of an EN should include examinations according to the clinical orientation:. Extended rest is desirable and may require work stoppage. Analgesics are prescribed on request. Venous compression reduces the pain felt in orthostatism. Etiologic treatment is essential in some cases, and antibiotic therapy is needed in case of streptococcal infection or anti-tuberculosis treatment.

The prognosis for patients with EN is good but there is a small risk of recurrence. The skin lesions often take months to resolve but there is usually no scarring or pigmentation change. EN is a noisy but benign syndrome, with a spontaneously favorable course, which is related to an underlying condition that needs to be diagnosed by clinical examination and some complementary oriented tests. In addition to symptomatic treatment, that of the underlying condition may be necessary.

EN is often encountered by primary care providers and nurse practitioners. While the diagnosis is clinical in most cases, sometimes a biopsy may be required to rule out another disorder. Healthcare workers should seek a consult with a dermatologist if there is any doubt about the diagnosis. For the most part, the treatment is conservative with rest. Primary care clinicians should not initiate any type of medical therapy if the diagnosis is uncertain.

In addition, since the diagnosis is clinical, the patient should not be subjected to unnecessary procedures. The type of laboratory workup depends on the suspected cause.

While EN may be painful, it is a benign disorder that usually remits spontaneously. If the primary disorder is not managed, EN may persist for months or even years. The pharmacist should ensure that the patient is on no medication that causes EN. If the female is on an oral contraceptive, then an alternative form of contraception should be recommended.

The primary care clinicians should communicate with the dermatologist to ensure that the patient is receiving the optimal level of care. Level V. To access free multiple choice questions on this topic, click here. Erythema nodosum. This book is distributed under the terms of the Creative Commons Attribution 4. Turn recording back on. National Center for Biotechnology Information , U. StatPearls [Internet]. Search term. Affiliations 1 Faculty of Medicine of Tunis, Tunisia.

Etiology Erythema nodosum can occur due to a vast number of underlying causes including but not limited to idiopathic, infectious, and a variety of noninfectious causes as outlined below. Sarcoidosis-Lofgren's syndrome a triad of erythema nodosum, acute arthritis, and hilar lymphadenopathy. Epidemiology EN is the most common clinical form of the acute nodular hypodermis. Pathophysiology EN is the result of a nonspecific cutaneous reaction to various antigens.

Histopathology Skin biopsy is not usually needed in the typical forms as a diagnosis can be reached from a detailed history and physical examination. History and Physical EN is characterized in a rather stereotyped way, whatever its cause, by the following evolutionary aspects: Prodromal Phase Nonspecific from 3 to 6 days.

Often a picture of infection nasopharyngeal, with a slight alteration of the general condition. The general syndrome occurs with fever, and arthralgia of the prodromal phase persists or increases.

Nodules appear on the extended faces of the legs and knees, and sometimes thighs and forearms. Nodules are small, 3 to 6, sometimes more, bilateral, roughly symmetrical, and spontaneously painful;. The clinical examination allows specifying the characters of the knots: 10 to 40 mm diameter; warm and firm on palpation, which accentuates their painful character; mobile in relation to the deep planes. The pain of the lesions is exacerbated by orthostatism, which leads the patient to spontaneously seek the lying position with raised legs.

Each nodule evolves in ten days, taking blue and yellowish contusiform aspects, towards complete disappearance without sequelae. Evaluation The positive diagnosis of EN is primarily clinical.

Taking into account the above, the etiological assessment of an EN should include examinations according to the clinical orientation: Blood count, vital signs, and C-reactive protein in case of infectious context ,. Differential Diagnosis Non-suppurative infectious dermphypodermitis diagnosis is easy.

Nodular hypodermitis with vascular involvement periarteritis nodosa, and superficial thrombophlebitis and damage to deep vessels of medium to sometimes large diameter is associated with hypodermic septal or lobular involvement. Nodules can become necrotic. The diagnosis is primarily histological. Lobular hypodermitis or panniculitis involves lesions that are primarily greasy.

The diagnosis is primarily histological, hence the absolute need for biopsy control. Several entities have been distinguished. The nodules can liquefy, fistulate, and leave a scar. Prognosis The prognosis for patients with EN is good but there is a small risk of recurrence. Pearls and Other Issues EN is a noisy but benign syndrome, with a spontaneously favorable course, which is related to an underlying condition that needs to be diagnosed by clinical examination and some complementary oriented tests.

Enhancing Healthcare Team Outcomes EN is often encountered by primary care providers and nurse practitioners. Questions To access free multiple choice questions on this topic, click here. Figure Erythema nodosum. References 1. Erythema nodosum and sarcoid granulomas - letting the cat out of the bag. Online J. A case of erythema nodosum-like panniculitis induced by nivolumab in a patient with oesophageal cancer.

Fujikawa T, Senoo A. Mayo Clin. Erythema nodosum in a patient with multiple sclerosis on dimethyl fumarate. Mult Scler Relat Disord.

Association of pyoderma gangrenosum, erythema nodosum and aseptic liver abscess without significant underlying disease. World J Pediatr.

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Erythema nodosum – review of the literature

Erythema nodosum EN , is an inflammatory condition characterized by inflammation of the fat cells under the skin , resulting in tender red nodules or lumps that are usually seen on both shins. The first signs of erythema nodosum are often flu-like symptoms such as a fever, cough, malaise , and aching joints. Some people also experience stiffness or swelling in the joints and weight loss. These subcutaneous nodules can appear anywhere on the body, but the most common sites are the shins, arms, thighs, and torso.

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Erythema nodosum

Erythema nodosum is the most common form of panniculitis. It may have many aetiological factors. Erythema nodosum occurs three to five times more often in female patients. It appears as erythematous painful rounded nodules, located most often on the anterior surface of the lower extremities, and may be accompanied by systemic symptoms such as fever, malaise and arthralgia.

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