Chronic Erythema Nodosum

Chronic erythema nodosum is a type of skin condition characterized by the appearance of red, tender, and painful nodules (lumps) on the legs. These nodules can range in size from a few millimeters to several centimeters and often appear symmetrically on both legs. The condition is considered “chronic” when it persists for more than six weeks.

Erythema nodosum is a type of panniculitis, which means that it affects the subcutaneous fat layer of the skin. It is a benign condition and does not typically result in scarring or permanent damage to the skin. However, it can be painful and cause discomfort, and the underlying cause of the condition should be addressed in order to prevent recurrence.

There are several different types of chronic erythema nodosum, each of which is caused by different underlying conditions. The types include:

1. Idiopathic Erythema Nodosum: This is the most common form of erythema nodosum, and the cause is unknown. It typically affects young women and resolves on its own within a few weeks to months.
2. Sarcoidosis-Associated Erythema Nodosum: Sarcoidosis is a systemic inflammatory disease that can affect multiple organs and tissues in the body. Erythema nodosum is a common skin manifestation of sarcoidosis, and it typically occurs in patients with established sarcoidosis.
3. Drug-Induced Erythema Nodosum: Certain medications, such as sulfonamides, penicillin, and hormonal contraceptives, have been known to cause erythema nodosum as a side effect. The condition typically resolves when the medication is discontinued.
4. Infection-Associated Erythema Nodosum: Certain infections, such as streptococcal pharyngitis (strep throat), tuberculosis, and fungal infections, can cause erythema nodosum. The nodules typically resolve when the underlying infection is treated.
5. Inflammatory Bowel Disease-Associated Erythema Nodosum: Erythema nodosum can occur in patients with inflammatory bowel disease, such as Crohn’s disease or ulcerative colitis. The nodules typically resolve when the underlying inflammation is treated.
6. Cancer-Associated Erythema Nodosum: Erythema nodosum can occur as a result of certain types of cancer, such as lymphoma or Hodgkin’s disease. The nodules typically resolve when the underlying cancer is treated.
7. Behçet’s Disease-Associated Erythema Nodosum: Behçet’s disease is a chronic, inflammatory condition that affects the blood vessels and can cause a range of symptoms, including erythema nodosum.

Causes

The following is a list of potential causes of chronic erythema nodosum:

1. Inflammatory bowel disease (IBD): CEN is commonly associated with IBD, including Crohn’s disease and ulcerative colitis.
2. Sarcoidosis: This is a systemic disease that can cause the formation of granulomas (small clusters of inflammatory cells) in various organs, including the skin.
3. Tuberculosis: Tuberculosis is a bacterial infection that can cause CEN in some individuals.
4. Streptococcal infections: Group A Streptococcal infections, such as strep throat, can trigger CEN in some people.
5. Fungal infections: Certain fungal infections, such as histoplasmosis and blastomycosis, have been linked to the development of CEN.
6. Viral infections: Viral infections, such as hepatitis B and C, can cause CEN as a side effect.
7. Certain medications: Certain medications, including penicillin, sulfonamides, and hydralazine, can cause CEN as a side effect.
8. Hormonal imbalances: Hormonal imbalances, such as those seen in pregnancy and thyroid disorders, can trigger CEN.
9. Cancer: Certain types of cancer, such as lymphoma and leukemia, have been linked to the development of CEN.
10. Rheumatoid arthritis: This autoimmune disease can cause joint pain, swelling, and stiffness, and it has also been linked to CEN.
11. Psoriasis: This chronic skin condition is characterized by thick, red, scaly patches on the skin, and it can also cause CEN.
12. Lupus: Systemic lupus erythematosus is an autoimmune disease that can cause a wide range of symptoms, including skin rashes and CEN.
13. Behcet’s disease: This is a rare autoimmune disease that can cause inflammation in various parts of the body, including the skin.
14. Ankylosing spondylitis: This is a type of arthritis that affects the spine and can cause CEN.
15. Inflammatory arthritis: This type of arthritis is characterized by inflammation of the joints and can cause CEN.
16. Chronic obstructive pulmonary disease (COPD): COPD is a lung disease that can cause CEN as a side effect.
17. Pregnancy: Pregnancy can cause hormonal imbalances and trigger CEN in some women.
18. Alcoholism: Alcoholism has been linked to the development of CEN in some individuals.
19. Hypersensitivity reactions: Hypersensitivity reactions, such as those seen in drug allergies, can cause CEN.
20. Idiopathic: In some cases, the cause of CEN is unknown and is referred to as idiopathic.

It’s important to note that CEN can be associated with a wide range of underlying conditions and may not always be a direct result of one of the causes listed above.

Symptoms

The following are the common symptoms of CEN:

1. Painful nodules or lumps: The most common and characteristic symptom of CEN is the presence of painful nodules or lumps on the shins and legs. The nodules are red, raised, and warm to the touch.
2. Swelling: The nodules are often accompanied by swelling in the affected area.
3. Redness: The skin over the nodules is usually red and inflamed.
4. Warmth: The affected area may feel warm to the touch.
5. Tenderness: The nodules are usually tender, and even the lightest touch can cause pain.
6. Itching: Some people with CEN may experience itching in the affected area.
7. Fatigue: Fatigue is a common symptom of CEN and may be due to the inflammation and pain caused by the condition.
8. Fever: A low-grade fever may be present in some individuals with CEN.
9. Joint pain: Some individuals with CEN may experience joint pain, particularly in the knees, ankles, and wrists.
10. Muscle aches: Muscle aches may also be present in some individuals with CEN.
11. Weight loss: Some individuals with CEN may experience unintended weight loss.
12. Anemia: Anemia, or a low red blood cell count, may be present in some individuals with CEN.
13. Mouth ulcers: Mouth ulcers may be present in some individuals with CEN.
14. Eye symptoms: Eye symptoms, such as redness, itching, and pain, may be present in some individuals with CEN.
15. Respiratory symptoms: Respiratory symptoms, such as cough and shortness of breath, may be present in some individuals with CEN.
16. Gastrointestinal symptoms: Gastrointestinal symptoms, such as abdominal pain and diarrhea, may be present in some individuals with CEN.
17. Nail changes: Nail changes, such as thickening and discoloration, may be present in some individuals with CEN.
18. Lymph node enlargement: Lymph node enlargement may be present in some individuals with CEN.
19. Skin rashes: Skin rashes may be present in some individuals with CEN.
20. Psychological symptoms: Psychological symptoms, such as depression and anxiety, may be present in some individuals with CEN.

It’s important to note that the symptoms of CEN can vary from person to person and may also change over time. Some individuals may experience only a few symptoms, while others may experience many of the symptoms listed above.

Diagnosis

diagnostic tests that can be used to diagnose chronic erythema nodosum:

1. Physical examination: The doctor will examine the skin for the presence of red, tender, and inflamed nodules or lumps on the shins and other parts of the legs.
2. Medical history: The doctor will ask about the patient’s medical history, including any recent infections, illnesses, injuries, or medications that may have triggered the development of erythema nodosum.
3. Blood tests: Blood tests can help to rule out other conditions that may cause similar symptoms, such as autoimmune diseases or infections. Common blood tests include a complete blood count (CBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) test.
4. Rheumatoid factor test: This test measures the levels of rheumatoid factor in the blood, which is often elevated in patients with autoimmune diseases.
5. Antinuclear antibody (ANA) test: This test measures the levels of antinuclear antibodies in the blood, which are often elevated in patients with autoimmune diseases.
6. HLA-B27 test: This test is used to determine whether the patient has a genetic predisposition to developing certain autoimmune diseases.
7. Tuberculin skin test: This test is used to determine whether the patient has been exposed to tuberculosis, which can cause erythema nodosum.
8. Chest X-ray: A chest X-ray can be used to rule out the presence of tuberculosis

Treatment

Treatment options for chronic erythema nodosum:

1. Corticosteroids: Corticosteroids are powerful anti-inflammatory medications that can reduce inflammation and swelling in the affected areas. They can be taken orally or applied topically.
2. Nonsteroidal anti-inflammatory drugs (NSAIDs): NSAIDs such as ibuprofen and naproxen can help relieve pain and reduce inflammation in the affected areas.
3. Colchicine: Colchicine is a medication that can help reduce the frequency and severity of attacks of erythema nodosum.
4. Dapsone: Dapsone is an antibiotic that has anti-inflammatory properties and can be used to treat chronic erythema nodosum.
5. Azathioprine: Azathioprine is an immunosuppressive medication that can be used to treat chronic erythema nodosum by reducing the activity of the immune system.
6. Methotrexate: Methotrexate is an immunosuppressive medication that can be used to treat chronic erythema nodosum.
7. Cyclosporine: Cyclosporine is an immunosuppressive medication that can be used to treat chronic erythema nodosum.
8. TNF-alpha inhibitors: TNF-alpha inhibitors, such as etanercept and infliximab, are medications that can help reduce inflammation by blocking the activity of TNF-alpha, a protein that contributes to inflammation.
9. Ustekinumab: Ustekinumab is a biologic medication that can be used to treat chronic erythema nodosum by blocking the activity of interleukin-12 and interleukin-23, two proteins that contribute to inflammation.
10. Phototherapy: Phototherapy involves exposing the skin to controlled amounts of ultraviolet (UV) light. UV light can help reduce inflammation and improve symptoms of chronic erythema nodosum.
11. Topical treatments: Topical treatments, such as creams and ointments, can be applied directly to the skin to relieve pain and reduce inflammation.
12. Warm compresses: Warm compresses can be applied to the affected areas to relieve pain and reduce swelling.
13. Cold compresses: Cold compresses can be applied to the affected areas to relieve pain and reduce swelling.
14. Massage therapy: Massage therapy can help relieve pain and improve circulation in the affected areas.
15. Acupuncture: Acupuncture is a traditional Chinese medicine technique that involves the insertion of fine needles into the skin at specific points to relieve pain and improve circulation.
16. Physical therapy: Physical therapy can help improve circulation and reduce pain in the affected areas.
17. Chiropractic care: Chiropractic care can help relieve pain and improve circulation in the affected areas.
18. Hydrotherapy: Hydrotherapy involves the use of water to relieve pain and improve circulation. This can be done in a spa, hot tub, or bathtub.

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