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Erythema nodosum

Kaveh G Shojania, MD
Section Editor
Jeffrey Callen, MD, FACP, FAAD
Deputy Editors
Abena O Ofori, MD
Paul L Romain, MD


Erythema nodosum (EN) is characterized by red or violet subcutaneous nodules that usually develop in a pretibial location. EN is presumed to represent a delayed hypersensitivity reaction to antigens associated with the various infectious agents, drugs, and other diseases with which it is associated, although the pathogenesis is largely unclear. EN occurs in a variety of disorders for which the etiology remains unknown; for example, sarcoidosis, inflammatory bowel disease, and Behçet’s disease.


The annual incidence of erythema nodosum (EN) is approximately 1 to 5/100,000 persons, most often women ages 15 to 40 years [1-5].


The majority of patients with erythema nodosum (EN) have evidence of recent streptococcal infection or have no identifiable cause; in such cases, symptomatic relief constitutes the only treatment necessary. However, in 15 to 40 percent of cases, EN represents an early sign of a variety of infections, connective tissue diseases, and other inflammatory disorders [1-3,6]. The frequency with which different diseases that have been associated with EN are found varies with the population studied (table 1) (see 'Causes of erythema nodosum' below). Thus, careful diagnostic assessment constitutes the most important aspect of management for patients presenting with EN.


In the majority of cases, painful, erythematous nodules develop on the anterior surfaces of both legs, and evolve into bruise-like lesions that resolve without scarring over a two- to eight-week period (picture 1) [2,3,6-9]. The lesions are deep nodules that may be more easily palpated than visualized. Lesions can also appear on the thighs, trunk, and upper extremities, but absence of nodules on the legs is atypical.

Polyarthralgia, fever, and malaise frequently accompany erythema nodosum (EN) (sometimes in advance of skin findings). The erythrocyte sedimentation rate is often elevated, but remains normal in 15 to 40 percent of cases [2,3,5,10].


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Literature review current through: Sep 2016. | This topic last updated: Nov 27, 2013.
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