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Erythema nodosum in Child
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Erythema nodosum in Child

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Contributors: Andrew Walls MD, Susan Burgin MD, Craig N. Burkhart MD, Dean Morrell MD, Nancy Esterly MD
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Synopsis

Erythema nodosum (EN) is the most common type of septal panniculitis (inflammation of the subcutaneous fat). EN has been associated with bacterial and viral infections (most commonly Streptococcus and Epstein-Barr, respectively), medications, malignancies, inflammatory bowel disease, fungal infections, and collagen vascular diseases. However, in 33%-50% of cases, no associations are found. A detailed list of etiologies is below.

The eruption persists for 3-6 weeks and spontaneously regresses without ulceration, scarring, or atrophy.

EN occurs in boys and girls in equal proportions before puberty (it rarely occurs before age 2); however, after puberty, females are more frequently affected, as in the adult population. Recurrences with reappearance of the precipitating factors are reported.

More commonly associated infections:
  • Streptococcus infection, especially pharyngitis
  • Mycoplasma
  • Upper respiratory viruses (Epstein-Barr virus [EBV])
  • Mycobacteria (tuberculosis [TB] and atypical)
  • Coccidioidomycosis in endemic areas
Less common infectious associations:
  • Yersinia, Shigella, Campylobacter, Salmonella sp. gastroenteritis
  • Cat-scratch disease, Chlamydia, syphilis, pertussis, leprosy, and numerous other bacterial infections
  • Hepatitis B, human immunodeficiency virus (HIV)
  • Blastomycosis, histoplasmosis, sporotrichosis, Giardia
Inflammatory etiologies:
  • Sarcoidosis
  • Inflammatory bowel disease
  • Behçet disease
Malignancy (especially leukemia)

Drugs:
  • Oral contraceptives, sulfonamides, penicillins, cephalosporins, macrolide antibiotics
Pregnancy

Codes

ICD10CM:
L52 – Erythema nodosum

SNOMEDCT:
32861005 – Erythema nodosum

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Diagnostic Pearls

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Differential Diagnosis & Pitfalls

Other forms of panniculitis:
  • Primary infectious panniculitis (see panniculitis) occurs through septic seeding or direct inoculation of a variety of infectious organisms. Tissue culture and polymerase chain reaction (PCR) aids in diagnosis.
  • Subacute migratory panniculitis is often more focal, painless, and unilateral.
  • Nodular vasculitis / erythema induratum is typically on the posterior calves and associated with pulmonary tuberculosis.
  • Pancreatic panniculitis favors the lower legs but is often ulcerated.
  • Lupus panniculitis favors the face and upper trunk. Most cases are not associated with systemic lupus erythematosus.
  • Panniculitis of dermatomyositis (abdomen, thighs, arms) is rare but may be the first manifestation of juvenile dermatomyositis.
  • Granulomatous panniculitis is a manifestation of subcutaneous granuloma annulare or sarcoidosis.
  • Post-steroid panniculitis is rare but exclusive to children. Occurs 1-10 days following withdrawal of systemic corticosteroids. May ulcerate and scar.
  • Cold panniculitis typically presents on the cheeks ("popsicle panniculitis") but may occur on any body site exposed to cold temperatures. Lateral thigh involvement of horseback riders has been described.
  • Injections, including iatrogenic and factitial.
  • Alpha-1 antitrypsin deficiency panniculitis is extremely rare in children but has been reported as an initial manifestation of the disease. Lesions frequently ulcerate.
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Management Pearls

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Therapy

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Drug Reaction Data

Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.

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References

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Last Updated: 06/15/2018
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Erythema nodosum in Child
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Erythema nodosum : Anterior lower leg, Arthralgia, Smooth plaques, Red
Clinical image of Erythema nodosum
Many erythematous and ecchymotic plaques of varying sizes on the lower legs.
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