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Chancroid

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Therapeutic Strategies

Erythema Nodosum

Timothy Berger Bruce Wintroub

Thursday, December 06, 2012

Overview

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, Beh├žet 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.

First Steps

  1. Bed rest with elevation, elastic stockings, and/or an Ace wrap may be all that is required for relief in 2-3 days.
  2. Aspirin or NSAIDs to tolerance may be added for analgesic effect and to enhance resolution.

Alternative Steps

  1. 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.
  2. Indomethacin 25-50 mg 3 times daily may be effective.

Subsequent Steps

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

  1. Colchicine 0.6-1.2 mg twice daily
  2. 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.
  3. 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 tuberculosis.

Pitfalls

  1. 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.
  2. The major pitfall is failure to identify and eradicate the underlying cause.
  3. 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 required.

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