What is the treatment for panniculitis?

Treatment of Panniculitis

The first-line treatment for panniculitis is systemic corticosteroids, typically prednisone at 1 mg/kg/day (up to 80 mg/day) for 1 month before tapering, with more severe cases requiring IV pulse methylprednisolone 500-1000 mg/day for 3-5 days before transitioning to oral prednisone. 1

Diagnostic Approach Before Treatment

Before initiating treatment, it's crucial to:

1. Determine the type of panniculitis through a deep excisional biopsy with adequate tissue for histopathological evaluation 1
2. Test for alpha-1 antitrypsin (AAT) deficiency in all cases of biopsy-proven severe panniculitis 1
3. Identify any underlying causes such as infections, drugs, systemic illnesses, or malignancy 2

Treatment Algorithm Based on Panniculitis Type

1. General Approach

• Initial therapy: Prednisone 1 mg/kg/day (up to 80 mg/day) for 1 month before tapering 1
• Severe cases: IV pulse methylprednisolone 500-1000 mg/day for 3-5 days before transitioning to oral prednisone 1
• Tapering schedule: Gradually reduce with goal of achieving low-dose (≤10 mg/day) or complete withdrawal 1

2. Specific Types of Panniculitis

Alpha-1 Antitrypsin Deficiency-Associated Panniculitis

• First-line: Augmentation therapy with purified human AAT or fresh frozen plasma 1
• Alternative for less severe cases: Dapsone alone or combined with augmentation therapy 1

Panniculitis Associated with IBD

• First-line: Treat the underlying IBD 1
• Refractory cases: Immunomodulators (azathioprine) or anti-TNF agents (infliximab, adalimumab) 1

Pyoderma Gangrenosum

• First-line: Systemic corticosteroids 1
• Refractory cases: Infliximab (>90% response in cases <12 weeks duration) 1
• Alternative options: Cyclosporine or tacrolimus (oral/IV) 1
• Localized cases: Topical tacrolimus 1

Erythema Nodosum

• Often resolves without specific treatment beyond supportive care 2
• Treat underlying cause if identified 2

Panniculitis Associated with Malignancy

• Treatment directed at the underlying malignancy 1
• For secondary hemophagocytic lymphohistiocytosis (HLH), etoposide has shown better survival outcomes 1

Monitoring and Potential Complications

• Monitor for steroid-related adverse effects: Blood pressure, blood glucose, weight changes, mood alterations, and signs of infection 1
• Watch for disease progression: Delayed treatment, particularly of pyoderma gangrenosum, can lead to debilitating outcomes 1

Common Pitfalls to Avoid

1. Overlooking AAT deficiency: Always test for AAT deficiency in severe panniculitis cases 1
2. Inappropriate steroid use: Can lead to ineffective or harmful treatment 1
3. Delayed diagnosis and treatment: Particularly important in pyoderma gangrenosum to prevent debilitating outcomes 1
4. Failure to identify and treat underlying causes: Many cases of panniculitis are secondary to other conditions 2

Treatment for Refractory Cases

For panniculitis that doesn't respond to first-line therapy:

• Consider immunomodulators: Azathioprine, methotrexate (note: methotrexate has been reported to cause panniculitis in rare cases) 3
• Biological agents: Anti-TNF agents like infliximab or adalimumab 1
• Calcineurin inhibitors: Cyclosporin A or tacrolimus 1

Remember that even without specific therapy, some forms of panniculitis like erythema nodosum typically resolve spontaneously, making symptomatic support adequate for many patients 2.