What is the management and treatment of Erythema nodosum?

Management and Treatment of Erythema Nodosum

The treatment of erythema nodosum should primarily focus on identifying and addressing the underlying cause, with supportive care for symptomatic relief. 1, 2

Diagnosis and Evaluation

• Erythema nodosum (EN) is characterized by raised, tender, red or violet subcutaneous nodules of 1-5 cm in diameter, typically affecting the extensor surfaces of the extremities, particularly the anterior tibial areas 1, 2
• Diagnosis is primarily made on clinical grounds based on characteristic features; biopsy is not usually necessary except in atypical cases 1
• A comprehensive evaluation should be conducted to identify potential underlying causes, including:
  • Streptococcal infection testing (throat culture, rapid antigen test, antistreptolysin-O titer) 2
  • Inflammatory markers (ESR, CRP) 2
  • Tuberculosis screening in high-risk patients 2
  • Evaluation for inflammatory bowel disease, sarcoidosis, and other systemic conditions 1, 3

Treatment Approach

First-Line Management

• Address the underlying condition if identified (e.g., treat streptococcal infection, manage inflammatory bowel disease) 1
• Supportive care measures:
  • Rest and elevation of affected extremities 1, 4
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) for pain and inflammation 2, 4
  • Compression bandages may provide symptomatic relief 5

Pharmacologic Treatment

• NSAIDs such as indomethacin or naproxen are first-line for symptomatic relief 4
• Potassium iodide may help enhance resolution in some cases 4
• Systemic corticosteroids are indicated in severe cases but should be used cautiously:
  • Typically reserved for cases with significant inflammation or when associated with inflammatory bowel disease flares 1
  • Should be used only after ruling out infectious causes 4, 6

Refractory Cases

• For persistent or recurrent EN associated with inflammatory bowel disease or other systemic conditions, consider:
  • Colchicine, particularly when EN is associated with Behçet's syndrome 1
  • Immunomodulators such as azathioprine for frequent relapses 1
  • Biologic agents (TNF-alpha inhibitors like infliximab or adalimumab) may be effective in resistant cases associated with inflammatory bowel disease 1

Special Considerations

• EN during pregnancy requires careful medication selection; consult with an obstetrician before prescribing any treatment 5
• EN associated with sarcoidosis may respond to hydroxychloroquine in addition to standard therapy 1
• EN typically resolves without scarring or ulceration, even without specific treatment 2, 4
• Recurrent EN may indicate persistent underlying disease activity and warrants reassessment 1

Common Pitfalls to Avoid

• Treating EN with systemic corticosteroids without ruling out infectious causes, which could worsen underlying infections 4, 6
• Failing to identify and address the underlying cause, leading to recurrent episodes 2, 3
• Overtreatment of self-limiting cases with aggressive immunosuppression when supportive care would be sufficient 6
• Neglecting to monitor for disease activity in associated conditions like inflammatory bowel disease or sarcoidosis 1

Remember that EN is typically self-limiting, with most cases resolving within 3-6 weeks even without specific treatment beyond supportive care 2, 4. However, proper identification and management of underlying causes are essential for preventing recurrence and complications.