Erythema Disease

BASICS

DESCRIPTION

Clinical pattern of multiple, bilateral, cutaneous, inflammatory, non-ulcerating, non-scarring eruptions that undergo characteristic color changes ending in temporary bruise-like areas. Occurs most commonly on the extensor surface of the shins, less common on thighs and forearms. It is often idiopathic, but may be seen as a response to a variety of clinical entities. Will usually subside in 3 to 6 weeks without scarring or atrophy.

System(s) affected: Skin/Exocrine
Genetics:
N/A
Incidence/Prevalence in USA:
Unknown
Predominant age: 20-30 years
Predominant sex: Female > Male (3:1)

SIGNS AND SYMPTOMS

Raised, warm, tender, brightly erythematous nodules located on anterior shins
Can also occur on any area with subcutaneous fat
Diameter 1-15 cm
Fever, malaise, chills
Arthralgias
Bluish discoloration late in course
Hilar adenopathy
Episcleral lesions
Eruptions often preceded by URI symptoms

CAUSES

Idiopathic
Bacterial - streptococcal infections, tuberculosis, leprosy, Yersinia enterocolitica, tularemia, Campylobacter, salmonella, Shigella, gonorrhea
Sarcoid
Drugs - sulfonamides, oral contraceptives, bromides
Pregnancy
Deep fungal - dermatophytes, coccidioidomycosis, histoplasmosis, blastomycosis
Viral/chlamydial - infectious mononucleosis, lymphogranuloma venereum, paravaccinia
Enteropathies - ulcerative colitis, Crohn's disease
Malignancies - lymphoma/leukemia, sarcoma, post radiation therapy

RISK FACTORS

Listed with Causes

DIAGNOSIS

LABORATORY

Elevated erythrocyte sedimentation rate
CBC: mild leukocytosis
Throat culture, ASO titers
Stool culture and leukocytes if indicated
Skin testing for mycobacteria if indicated

Drugs that may alter lab results: Antecedent antibiotics may affect cultures
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS

Septal panniculitis
Neutrophilic infiltrate in septa of fat tissue, early in course
Mononuclear cells and histiocytes predominate, late in course
Lower dermis/subcutis involvement and septal fibrosis may occur

SPECIAL TESTS

N/A

IMAGING

Chest x-ray for hilar adenopathy or infiltrates

DIAGNOSTIC PROCEDURES

Deep skin excisional biopsy including subcutaneous fat. Usually not necessary.

TREATMENT

APPROPRIATE HEALTH CARE

Outpatient

GENERAL MEASURES

Wet dressings (hot soaks and topical medications are not useful)
Discontinue potentially causative drugs
Treat underlying disease

SURGICAL MEASURES

N/A

ACTIVITY

Bedrest, keep legs elevated
Elastic wraps or support stockings may be helpful if patients want to be up and around

DIET

No restrictions

PATIENT EDUCATION

Lesions will resolve over a few months
No scarring is anticipated
Joint aches and pains may persist
Less than 20% recur

FOLLOW UP

PREVENTION/AVOIDANCE

N/A

POSSIBLE COMPLICATIONS

Vary according to underlying disease. None expected from lesions of erythema nodosum.

EXPECTED COURSE AND PROGNOSIS

Individual lesions resolve over 3-6 week course
Total time course of 6-12 weeks, but may vary with etiologic disease if present
Joint aches and pains may persist for years
Lesions do not scar
One or more recurrences in 12-14% of cases; these occur over variable periods, averaging several years, seen most often with sarcoid, streptococcal infection, pregnancy, and oral contraceptives

MISCELLANEOUS

ASSOCIATED CONDITIONS

See Causes

AGE-RELATED FACTORS

Pediatric: Incidence equal male and female
Geriatric: N/A
Others: N/A

PREGNANCY

May have repeat outbreaks during pregnancy

OTHER NOTES

Lofgren's syndrome (erythema nodosum and hilar adenopathy) is seen with multiple etiologies and does not exclusively indicate sarcoid
Clinical variant of erythema nodosum migrans (subacute nodular migratory panniculitis) is often unilateral with nodules fewer in number, smaller in size and longer lasting, often extending radially by division into smaller nodules

ABBREVIATIONS

N/A

Clinical Investigations

ROLE OF HOMOEOPATHY

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