Thursday, December 06, 2012
Erythema nodosum is a reactive inflammatory septal panniculitis
produced by multiple agents and underlying conditions. The most
important consideration in the management of erythema nodosum is to
determine and treat the cause. In children, streptococcal infection
is the most common trigger. In adults, drugs, sarcoidosis,
inflammatory bowel disease, Behçet syndrome, deep fungal infection,
and malignancy among others may all be triggers. Women are much
more frequently affected than men. Estrogens in OCPs are an
important cofactor in this condition, and they should be
discontinued if possible. Treatment of the cutaneous lesions is
symptomatic and empiric.
- Bed rest with elevation, elastic stockings, and/or an Ace wrap
may be all that is required for relief in 2-3 days.
- Aspirin or NSAIDs to tolerance may be added for analgesic
effect and to enhance resolution.
- Oral potassium iodide (SSKI) 300 mg (5 or 6 drops) 3 times
daily initially, increased by 1 drop/dose/day to resolution, is
often dramatically beneficial. The patient is maintained on the
dose that is adequate for response for a total of 3 weeks.
- Indomethacin 25-50 mg 3 times daily may be effective.
Initial positive response
Do not discontinue therapy too rapidly in those patients
responding to the above treatments. Continuation of therapy for 2-3
weeks reduces recurrences.
Failure to respond to the above treatments
- Colchicine 0.6-1.2 mg twice daily
- Intralesional triamcinolone acetonide 5 mg/cc to the center of
individual lesions will cause them to resolve. This is good
treatment if there are few lesions.
- Systemic corticosteroids in moderate doses (20-40 mg/day) will
clear most cases. This therapy can only be used after the
underlying cause has been identified and, if infectious, has been
treated appropriately. Systemic steroids are contraindicated in
those cases triggered by systemic fungal infections or
- The most frequent reason for relapse is too rapid resumption of
physical activity (jogging, aerobics classes, etc). If the patient
requests exercise options, swimming can be recommended.
- The major pitfall is failure to identify and eradicate the
- Clinically erythema nodosum and other panniculitides may not be
easy to differentiate. In all but absolutely classical cases, an
excisional biopsy, including adequate subcutaneous fat, is