Erythema nodosum is an inflammatory lesion of the skin and subcutaneous vessels, having an allergic genesis and manifested by the formation of dense painful hemispherical inflammatory nodes of various sizes. Most often, the process is localized on symmetrical areas of the lower extremities. Diagnosis is based on data from dermatological examination, laboratory tests, lung radiography, the conclusion of a pulmonologist, rheumatologist and other specialists. Therapy includes the elimination of foci of infection, antibiotic therapy, general and local anti-inflammatory therapy, extracorporeal hemocorrection, the use of VLOK and physiotherapy.
The name “erythema nodosum” was introduced by the British dermatologist Robert Villan in 1807g. For a long time, the disease was considered a specific nosological unit. Later in dermatology, studies were conducted that proved that erythema nodosum is one of the variants of allergic vasculitis. Unlike systemic vasculitis, disease is characterized by a local vascular lesion, limited mainly to the lower extremities.
Erythema nodosum disease affects people of any age category, but it is most often observed in patients aged 20-30 years. Before puberty, the prevalence is the same among men and women, after puberty, the incidence in women is 3-6 times higher than in men. An increase in cases of this disease in the winter-spring period is characteristic.
Erythema nodosum causes
The main cause of sensitization of the body with the development of erythema nodosum are various infectious processes in the body. First of all, these are streptococcal infections (sore throat, scarlet fever, acute pharyngitis, streptodermia, erysipelas, otitis, cystitis, rheumatoid arthritis, etc.) and tuberculosis, less often — yersiniosis, coccidiomycosis, trichophytia, inguinal lymphogranulomatosis. The disease can also occur due to drug sensitization. The most dangerous drugs in this regard are salicylates, sulfonamides, iodides, bromides, antibiotics and vaccines.
Often erythema nodosum accompanies sarcoidosis. More rare non-infectious causes of its development include Behcet’s disease, ulcerative colitis, inflammatory bowel diseases (Crohn’s disease, colitis, paraproctitis), oncological pathology, pregnancy. There are family cases of erythema nodosum associated with a hereditary predisposition to sensitization of the body by infectious or other agents. Patients with vascular disorders (varicose veins, atherosclerosis of the vessels of the lower extremities), allergic diseases (pollinosis, bronchial asthma, atopic dermatitis) are predisposed to the development of erythema nodosum with a chronic course or foci of chronic infection (tonsillitis, sinusitis, pyelonephritis).
Erythema nodosum symptoms
A typical manifestation is dense nodes located in the lower parts of the dermis or in the subcutaneous tissue. The diameter of the nodes varies from 5 mm to 5 cm. The skin above them is smooth and colored red. The elements rise somewhat above the general level of the skin, their boundaries are blurred due to the swelling of the surrounding tissues. Rapidly growing to a certain size, the nodes stop growing. Pain syndrome in patients can have different severity and is noted not only during palpation of nodes, but also spontaneously. There is no itching. After 3-5 days, the resolution of the nodes begins, which is manifested by their compaction and is not accompanied by decay. Characteristic of erythema nodosum is a change in the color of the skin above the nodes, which resembles the process of resolving a bruise. Initially red, it becomes brown, and then bluish, greenish and yellow.
The most typical localization of nodes is the anterior surface of the shins. The symmetry of the lesion is more often observed, but a unilateral or isolated nature of the rash is possible. Elements of erythema nodosum can occur wherever there is subcutaneous fat: on the thighs, calves, buttocks, forearms, face and even the episclere of the eyeball.
In most cases, disease has an acute onset and is accompanied by fever, anorexia, general malaise, chills. Approximately 2/3 of patients have arthropathies: joint pain (arthralgia), soreness when probing, stiffness in the morning. In 1/3 of patients with erythema nodosum, subjective symptoms are accompanied by objective signs of inflammation in the joint (arthritis): swelling and redness of the skin in the joint area, an increase in local temperature, the presence of intra-articular effusion. Articular syndrome in erythema nodosum is characterized by a symmetrical lesion of large joints. Swelling of small joints of the feet and hands is possible. General symptoms and arthropathies may be several days ahead of the appearance of skin elements.
As a rule, within 2-3 weeks there is a complete resolution. In their place, temporary hyperpigmentation and peeling may occur. Simultaneously with the skin symptoms, the articular syndrome also passes. In total, the acute form lasts about 1 month.
Much less frequently, erythema nodosum has a persistently recurrent chronic course. Exacerbations of the disease are manifested by the appearance of a small number of single bluish-pink nodes of dense consistency, which persist for several months. Skin manifestations may be accompanied by chronic arthropathy, occurring without deformity of the joints.
Changes in laboratory data in erythema nodosum are non-specific. However, they make it possible to differentiate the disease from other disorders, to identify its cause and concomitant pathology. In a clinical blood test in the acute period or with a relapse of chronic erythema nodosum, neutrophilic leukocytosis and increased ESR are observed. Bacposev from the nasopharynx often reveals the presence of streptococcal infection. If yersiniosis is suspected, fecal bacposev is performed, tuberculin diagnostics is performed to exclude tuberculosis. Pronounced articular syndrome is an indication for a rheumatologist’s consultation and a blood test for rheumatoid factor.
In difficult cases, to confirm the diagnosis of erythema nodosum, a dermatologist prescribes a biopsy of one of the nodular formations. Histological examination of the obtained material reveals the presence of an inflammatory process in the walls of small arteries and veins, in the interlobular septa at the border of the dermis and subcutaneous tissue.
Determination of the etiological factor of erythema nodosum, concomitant foci of chronic infection or vascular disorders may require consultation with a pulmonologist, an infectious disease specialist, an otolaryngologist, a vascular surgeon, a phlebologist, and other specialists. For the same purpose, when diagnosing erythema nodosum, rhinoscopy and pharyngoscopy, CT and lung radiography, rheovasography of the lower extremities, ultrasound of the veins of the lower extremities, etc., can be prescribed. Lung x-ray is aimed at identifying concomitant sarcoidosis, tuberculosis or other process in the lungs. At the same time, a common, but not mandatory radiological companion of erythema nodosum is a one- or two-sided enlargement of the lymph nodes of the lung root.
Erythema nodosum treatment
The effectiveness of therapy of erythema nodosum largely depends on the results of treatment of causal or concomitant pathology. Rehabilitation of chronic foci of infection, systemic antibiotic therapy, desensitizing therapy is performed. To relieve inflammatory phenomena and relieve pain in erythema nodosum, nonsteroidal anti-inflammatory drugs are prescribed: diclofenac, ibuprofen, etc. The use of extracorporeal hemocorrection methods (cryoapheresis, plasmapheresis, hemosorption) and laser irradiation of blood contributes to the speedy regression of symptoms.
Anti-inflammatory and corticosteroid ointments are applied topically, bandages with dimexide are applied to the area of inflamed joints. Of the physiotherapeutic methods, UVI in erythema nodosum, magnetotherapy, laser therapy, phonophoresis with hydrocortisone on the area of inflammatory nodes or affected joints have a good effect in this pathology.
The greatest difficulties in treatment arise with the development of disease during pregnancy, since many medications are contraindicated during this period.