From the Guidelines
Erythema nodosum is a painful skin condition that should be treated with systemic corticosteroids in severe cases, and immunomodulators or anti-TNF agents can be used for relapsing and resistant forms, as recommended by the most recent evidence-based consensus 1. The diagnosis of erythema nodosum is typically made on clinical grounds, with a skin biopsy considered only in atypical cases 1. For symptom relief, patients can be advised to:
- Rest and elevate the affected legs to reduce swelling
- Apply cool compresses to the nodules
- Use over-the-counter pain relievers like ibuprofen (400-600 mg every 6-8 hours) or naproxen (220-440 mg every 12 hours) for pain and inflammation It is essential to identify and treat the underlying cause of erythema nodosum, which may include:
- Infections (streptococcal, tuberculosis)
- Medications (oral contraceptives, antibiotics)
- Inflammatory bowel disease
- Sarcoidosis
- Pregnancy According to the European evidence-based consensus, treatment of erythema nodosum is usually based on that of the underlying inflammatory bowel disease (IBD) 1. Colchicine should be preferred when the dominant lesion is erythema nodosum, as suggested by the EULAR recommendations for the management of Behçet disease 1. However, the most recent and highest quality study recommends systemic corticosteroids and immunomodulators or anti-TNF agents for the treatment of erythema nodosum 1. Erythema nodosum is often self-limiting and resolves within 3-6 weeks, but addressing the root cause is essential for preventing recurrence and ensuring overall health.
From the Research
Diagnosis of Erythema Nodosum
- Erythema nodosum is characterized by tender, erythematous, subcutaneous nodules typically located on the lower limbs, often bilaterally distributed 2, 3, 4, 5.
- The diagnosis of erythema nodosum involves a comprehensive history and physical examination, including a deep incisional or excisional biopsy specimen for adequate visualization 5.
- Diagnostic evaluation includes complete blood count with differential, erythrocyte sedimentation rate, C-reactive protein level, testing for streptococcal infection, and biopsy 5.
- Patients should be stratified by risk for tuberculosis, and further evaluation may include purified protein derivative test, chest radiography, and stool cultures 5.
Treatment of Erythema Nodosum
- Treatment of erythema nodosum should be directed to the underlying associated condition, if identified 2, 4, 5.
- Erythema nodosum tends to be self-limited, and any underlying disorders should be treated, with supportive care provided 5.
- Therapeutic options consist mainly of nonsteroidal anti-inflammatory drugs, symptomatic care, potassium iodide, and colchicine 2, 6.
- Compression stockings may be an effective treatment for erythema nodosum, as shown in a case series where two female patients with recurrent erythema nodosum experienced lasting clinical resolution after wearing moderate 20 mmHg to 30 mmHg compression stockings daily 3.
- Systemic corticosteroids are rarely indicated in erythema nodosum and should only be administered after ruling out an underlying infection 2.