Management of Erythema Nodosum
For erythema nodosum, NSAIDs (such as ibuprofen or naproxen) are the first-line treatment for symptomatic relief, with systemic corticosteroids reserved only for severe cases after excluding infectious causes, particularly tuberculosis. 1, 2
Initial Treatment Approach
First-Line Therapy: NSAIDs
- NSAIDs are the cornerstone of symptomatic treatment for pain and inflammation in erythema nodosum 1
- Effective options include ibuprofen, naproxen, indomethacin, or aspirin 2, 3
- These agents typically provide sufficient analgesia and enhance resolution of nodules 2
- Bed rest and leg elevation are important adjunctive measures that accelerate improvement 2, 4
Address Underlying Causes
- Identify and treat any precipitating condition: streptococcal pharyngitis (most common in children), sarcoidosis (common in adults), inflammatory bowel disease, or fungal infections 1, 4
- For streptococcal infection, appropriate antibiotic therapy is essential 4
- For Behçet's disease-associated erythema nodosum, colchicine is the preferred treatment 5, 1
When to Use Corticosteroids
Indications for Systemic Corticosteroids
- Reserve corticosteroids for severe cases with significant inflammation or IBD-associated erythema nodosum 1
- Corticosteroids are highly effective but rarely indicated due to the self-limited nature of erythema nodosum 2, 3
Critical Caveat: Rule Out Infection First
- Before administering corticosteroids, you must exclude underlying infections, particularly tuberculosis and fungal infections 2, 6
- Risk-stratify patients for tuberculosis with purified protein derivative testing and chest radiography as needed 4
- For coccidioidomycosis-associated erythema nodosum, antifungal therapy is not recommended; NSAIDs alone are sufficient 1
Refractory or Recurrent Cases
Second-Line Immunomodulatory Therapy
- For frequent relapses or IBD-associated erythema nodosum, consider azathioprine or TNF-alpha inhibitors (infliximab or adalimumab) 1
- Colchicine is particularly effective when erythema nodosum is associated with Behçet's syndrome 5, 1
- For sarcoidosis-associated cases, hydroxychloroquine may be added to standard therapy 1
Additional Options
- Potassium iodide may be helpful to enhance analgesia and resolution 2
- Topical or oral calcineurin inhibitors are alternatives in resistant cases, though dermatological consultation is recommended 5
Common Pitfalls to Avoid
- Do not use corticosteroids without first excluding infectious etiologies, as steroids risk disseminating underlying infections like tuberculosis or fungal disease 2, 6, 7
- Do not overlook the need to monitor for disease activity in associated conditions like inflammatory bowel disease or sarcoidosis 1
- Recognize that over 50% of patients may have recurrent episodes, which warrants reassessment for persistent underlying disease 1, 7
- Remember that erythema nodosum is self-limited in most cases, resolving spontaneously within weeks without scarring or ulceration 2, 4, 3