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Erythema Nodosum: Causes, Symptoms and Treatment

Erythema nodosum is an inflammatory skin condition causing painful, red nodules, most commonly on the shins. It is a reactive skin pattern triggered by various underlying causes.

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Things worth knowing about "Erythema nodosum"

Erythema nodosum is an inflammatory skin condition causing painful, red nodules, most commonly on the shins. It is a reactive skin pattern triggered by various underlying causes.

What is Erythema nodosum?

Erythema nodosum is an inflammatory condition affecting the subcutaneous fat layer of the skin (panniculitis), characterized by painful, red, raised nodules that appear primarily on the shins and lower legs. It is not a disease in itself but rather a reactive skin response of the immune system to a variety of internal or external triggers. Women are affected more frequently than men, and the condition most commonly occurs between the ages of 20 and 40.

Causes

Erythema nodosum can be triggered by a wide range of factors. In many cases, no specific cause can be identified (idiopathic form). The most common known triggers include:

Infections: Especially streptococcal throat infections, tuberculosis, Yersinia, Chlamydia, and fungal infections (e.g., histoplasmosis)
Chronic inflammatory bowel diseases: Crohn's disease, ulcerative colitis
Sarcoidosis: A systemic granulomatous disease frequently associated with erythema nodosum
Medications: Sulfonamides, oral contraceptives, penicillin, bromides
Pregnancy: Hormonal changes may predispose individuals to the condition
Malignancies: Rarely, as a paraneoplastic phenomenon

Symptoms

The typical symptoms of erythema nodosum include:

Painful, tender nodules measuring 1 to 5 cm in diameter, located deep within the skin
Redness and warmth over the affected skin areas
Preferred location on the extensor surfaces of the lower legs; less commonly on the thighs, forearms, or trunk
General symptoms such as fever, fatigue, and joint pain (arthralgia)
Over time, the nodules change color similarly to a bruise (from red to blue-violet and finally yellow-green) and typically resolve within 3 to 8 weeks without scarring

Diagnosis

Diagnosis is primarily clinical, based on the characteristic skin findings and medical history. Additional investigations are used to identify the underlying cause:

Blood tests: Complete blood count, inflammatory markers (CRP, ESR), antistreptolysin O titer (ASOT), angiotensin-converting enzyme (ACE) if sarcoidosis is suspected
Cultures and swabs: To detect bacterial or fungal infections
Chest X-ray: To exclude tuberculosis or sarcoidosis
Skin biopsy: In unclear cases, for histological confirmation; the typical finding is septal panniculitis without vasculitis

Treatment

Treatment primarily targets the underlying cause. In addition, symptomatic measures can help relieve discomfort:

General Measures

Physical rest and leg elevation to reduce swelling
Cool compresses for pain relief

Medical Treatment

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen for pain relief and reduction of inflammation
Potassium iodide may be used in recurrent erythema nodosum
Corticosteroids (e.g., prednisolone) in severe or persistent cases, but only after infectious causes have been excluded
Treatment of the underlying condition (e.g., antibiotics for streptococcal infections, specific therapy for Crohn's disease or sarcoidosis)

Prognosis

Erythema nodosum resolves spontaneously and completely in most cases within 4 to 8 weeks. Recurrences are possible, especially if the underlying trigger persists. Scarring does not typically occur.

References

Schwartz, R.A. & Nervi, S.J. (2007): Erythema nodosum: a sign of systemic disease. In: American Family Physician, 75(5), 695-700.
Mert, A. et al. (2004): Erythema nodosum: an evaluation of 100 cases. In: Clinical and Experimental Rheumatology, 22(5), 617-618.
Requena, L. & Yus, E.S. (2001): Panniculitis. Part I. Mostly septal panniculitis. In: Journal of the American Academy of Dermatology, 45(2), 163-183.

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