What is the treatment for erythema nodosum?

Treatment of Erythema Nodosum

Colchicine should be the first-line treatment for erythema nodosum, especially when it is the dominant lesion. 1

Diagnosis and Etiology

Erythema nodosum (EN) is characterized by:

• Raised, tender, red or violet subcutaneous nodules of 1-5 cm in diameter
• Typically affects the extensor surfaces of the extremities, particularly the anterior tibial areas
• Often accompanied by systemic symptoms including arthralgia and fatigue
• More common in women than men

Before initiating treatment, it's important to identify any underlying causes, as EN can be associated with:

• Streptococcal infections
• Tuberculosis
• Sarcoidosis
• Inflammatory bowel disease
• Behçet's syndrome
• Medications (including oral contraceptives)
• Pregnancy

Treatment Algorithm

First-line Treatment

• Colchicine is the preferred first-line treatment for erythema nodosum, particularly when it is the dominant lesion 1
• NSAIDs (e.g., acetylsalicylic acid, ibuprofen, naproxen, indomethacin) for symptomatic relief of pain and inflammation 2

Second-line Treatment

• Systemic corticosteroids for severe cases that don't respond to first-line therapy 1
  • Brief courses of corticosteroids are recommended to minimize side effects
  • Should be used cautiously due to potential adverse effects

Treatment of Resistant Cases

For resistant cases or frequent relapses:

• Azathioprine 1
• TNF-α antagonists (infliximab, adalimumab) 1

Special Considerations

Underlying Conditions

• Treatment should address any identified underlying cause:
  • Antibiotics for streptococcal infections
  • Appropriate therapy for tuberculosis, sarcoidosis, or inflammatory bowel disease
  • Discontinuation of causative medications

Behçet's Syndrome

In patients with Behçet's syndrome and erythema nodosum:

• Colchicine is particularly effective and should be the first choice 1
• For resistant cases, consider azathioprine, interferon-alpha, or TNF-α antagonists 1

Inflammatory Bowel Disease

In patients with inflammatory bowel disease and erythema nodosum:

• Treatment is based on managing the underlying IBD activity 1
• Systemic corticosteroids may be required in severe cases 1

Supportive Measures

• Rest and elevation of the affected limbs
• Compression stockings to reduce edema
• Avoidance of prolonged standing or sitting
• Adequate pain management

Monitoring and Follow-up

• Regular follow-up to assess treatment response
• Monitor for recurrence after treatment discontinuation
• Evaluate for any signs of underlying disease progression

Prognosis

Erythema nodosum is typically self-limited and resolves without scarring within 3-6 weeks, though it may persist longer in some cases. The prognosis is generally good, especially when any underlying cause is identified and treated appropriately.