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ERROR: type should be string, got "https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvMTA4MTYzMy1vdmVydmlldw==\nDrugs & Diseases > Dermatology\nErythema Nodosum\nAuthor: Jeanette L Hebel, MD; Chief Editor: William D James, MD more...\nSections Erythema Nodosum\nAntithyroid agents\nErythema nodosum (EN) is an acute, nodular, erythematous eruption that usually is limited to the extensor aspects of the lower legs. Chronic or recurrent erythema nodosum is rare but may occur. Erythema nodosum is presumed to be a hypersensitivity reaction and may occur in association with several systemic diseases or drug therapies, or it may be idiopathic. The inflammatory reaction occurs in the panniculus.\nErythema nodosum probably is a delayed hypersensitivity reaction to a variety of antigens; circulating immune complexes have not been found in idiopathic or uncomplicated cases but may be demonstrated in patients with inflammatory bowel disease. [1]\nCurrently, the most common cause of erythema nodosum is streptococcal infection in children and streptococcal infection and sarcoidosis in adults. [2] Numerous other causes have been reported. [3] The causes reported most often in the literature are described below.\nStreptococcal infections are one of the most common causes of erythema nodosum. [4] Tuberculosis was an important cause in the past, but it has decreased dramatically as a cause for erythema nodosum; however, it still must be excluded, especially in developing countries. [5, 6] Yersinia enterocolitica is a gram-negative bacillus that causes acute diarrhea and abdominal pain; it is a common cause of erythema nodosum in France and Finland. [7, 8, 9] Mycoplasma pneumoniae infection may cause erythema nodosum. Erythema nodosum leprosum clinically resembles erythema nodosum, but the histologic picture is that of leukocytoclastic vasculitis. Lymphogranuloma venereum may cause erythema nodosum. Salmonella infection may cause erythema nodosum. Campylobacter infection may cause erythema nodosum.\nCoccidioidomycosis (San Joaquin Valley fever) is the most common cause of erythema nodosum in the American Southwest. In approximately 4% of males and 10% of females, the primary fungal infection (which may be asymptomatic or involve symptoms of upper respiratory infection) is followed by the development of erythema nodosum. Lesions appear 3 days to 3 weeks after the end of the fever caused by the fungal infection. Histoplasmosis may cause erythema nodosum. Blastomycosis may cause erythema nodosum.\nSulfonamides and halide agents are an important cause of erythema nodosum. Drugs more recently described to cause erythema nodosum include gold and sulfonylureas. Oral contraceptive pills are implicated in an increasing number of reports. [10]\nEnteropathies\nUlcerative colitis and Crohn disease may trigger erythema nodosum. Erythema nodosum associated with enteropathies correlates with flares of the disease. The mean duration of chronic ulcerative colitis before the onset of erythema nodosum is 5 years, and erythema nodosum is controlled with adequate therapy of the colitis. Erythema nodosum is the most frequent dermatologic symptom in inflammatory bowel diseases, and it is strongly associated with Crohn disease. [11, 12]\nHodgkin disease and lymphoma\nErythema nodosum associated with non-Hodgkin lymphoma may precede the diagnosis of lymphoma by months. Reports of erythema nodosum preceding the onset of acute myelogenous leukemia have been published. [13, 14]\nApproximately 10-22% of all erythema nodosum cases are caused by sarcoidosis. [15] The most common cutaneous manifestation of sarcoidosis is erythema nodosum. [16] A characteristic form of acute sarcoidosis involves the association of erythema nodosum, hilar lymphadenopathy, fever, arthritis, and uveitis, which has been termed Löfgren syndrome. This presentation has a good prognosis, with complete resolution within several months in most patients. HLA-DRB1*03 is associated with Löfgren syndrome. Most DRB1*03-positive patients have resolution of their symptoms within 2 years; however, nearly half of DRB1*03-negative patients have an unremitting course. [17]\nBehçet disease\nThis condition is associated with erythema nodosum.\nSome patients develop erythema nodosum during pregnancy, most frequently during the second trimester. Repeated episodes occur with subsequent pregnancies or with the use of oral contraceptives.\nPeak incidence occurs at age 18-34 years. Age and sex distributions vary according to etiology and geographic location. [18]\nRates of erythema nodosum vary according to country. In England, the rate is 2.4 cases per 10,000 per year.\nWomen are affected more often than men, with a male-to-female ratio of 1:4.\nErythema nodosum may occur in children and in patients older than 70 years, but it is more common in young adults aged 18-34 years. Age distribution varies with geographic location and etiology.\nIn patients with erythema nodosum, the prognosis is excellent. In most patients, erythema nodosum resolves without any adverse reactions.\nInstruct patients that the restriction of physical activities may help shorten the course of erythema nodosum.\nNguyen GC, Torres EA, Regueiro M, et al. Inflammatory bowel disease characteristics among African Americans, Hispanics, and non-Hispanic Whites: characterization of a large North American cohort. Am J Gastroenterol. 2006 May. 101(5):1012-23. [Medline].\nPsychos DN, Voulgari PV, Skopouli FN, Drosos AA, Moutsopoulos HM. Erythema nodosum: the underlying conditions. Clin Rheumatol. 2000. 19(3):212-6. [Medline].\nMert A, Ozaras R, Tabak F, Ozturk R. Primary tuberculosis cases presenting with erythema nodosum. J Dermatol. 2004 Jan. 31(1):66-8. [Medline].\nWheeler DJ, Cascino T, Sharpe BA, Connor DM. When the Script Doesn't Fit: An Exercise in Clinical Reasoning. J Gen Intern Med. 2017 Mar 23. [Medline].\nKakourou T, Drosatou P, Psychou F, Aroni K, Nicolaidou P. Erythema nodosum in children: a prospective study. J Am Acad Dermatol. 2001 Jan. 44(1):17-21. [Medline].\nRequena L, Yus ES. Erythema nodosum. Dermatol Clin. 2008 Oct. 26(4):425-38, v. [Medline].\nBottone EJ. Yersinia enterocolitica: the charisma continues. Clin Microbiol Rev. 1997 Apr. 10(2):257-76. [Medline].\nPolcari IC, Stein SL. Panniculitis in childhood. Dermatol Ther. 2010 Jul-Aug. 23(4):356-67. [Medline].\nGarcía-Porrúa C, González-Gay MA, Vázquez-Caruncho M, López-Lazaro L, Lueiro M, Fernández ML, et al. Erythema nodosum: etiologic and predictive factors in a defined population. Arthritis Rheum. 2000 Mar. 43(3):584-92. [Medline].\nMin MS, Fischer R, Fournier JB. Unilateral Erythema Nodosum following Norethindrone Acetate, Ethinyl Estradiol, and Ferrous Fumarate Combination Therapy. Case Rep Obstet Gynecol. 2016. 2016:5726416. [Medline].\nFarhi D, Cosnes J, Zizi N, et al. Significance of erythema nodosum and pyoderma gangrenosum in inflammatory bowel diseases: a cohort study of 2402 patients. Medicine (Baltimore). 2008 Sep. 87(5):281-93. [Medline].\nRichter L, Rappersberger K. [Cutaneous involvement in chronic inflammatory bowel disease : Crohn's disease and ulcerative colitis]. Hautarzt. 2016 Dec. 67 (12):940-947. [Medline].\nSullivan R, Clowers-Webb H, Davis MD. Erythema nodosum: a presenting sign of acute myelogenous leukemia. Cutis. 2005 Aug. 76(2):114-6. [Medline].\nPolat A, Dinulescu M, Fraitag S, Nimubona S, Toutain F, Jouneau S, et al. Skin manifestations among GATA2-deficient patients. Br J Dermatol. 2017 Apr 25. [Medline].\nWanat KA, Rosenbach M. Cutaneous Sarcoidosis. Clin Chest Med. 2015 Dec. 36 (4):685-702. [Medline].\nAmschler K, Seitz CS. [Cutaneous manifestations of sarcoidosis]. Z Rheumatol. 2017 Jun. 76 (5):382-390. [Medline].\nGrunewald J, Eklund A. Lofgren's syndrome: human leukocyte antigen strongly influences the disease course. Am J Respir Crit Care Med. 2009 Feb 15. 179(4):307-12. [Medline].\nMert A, Ozaras R, Tabak F, Pekmezci S, Demirkesen C, Ozturk R. Erythema nodosum: an experience of 10 years. Scand J Infect Dis. 2004. 36(6-7):424-7. [Medline].\nMoraes AJ, Soares PM, Zapata AL, Lotito AP, Sallum AM, Silva CA. Panniculitis in childhood and adolescence. Pediatr Int. 2006 Feb. 48(1):48-53. [Medline].\nRequena L, Yus ES. Panniculitis. Part I. Mostly septal panniculitis. J Am Acad Dermatol. 2001 Aug. 45(2):163-83; quiz 184-6. [Medline].\nSterling JB, Heymann WR. Potassium iodide in dermatology: a 19th century drug for the 21st century-uses, pharmacology, adverse effects, and contraindications. J Am Acad Dermatol. 2000 Oct. 43(4):691-7. [Medline].\nGilchrist H, Patterson JW. Erythema nodosum and erythema induratum (nodular vasculitis): diagnosis and management. Dermatol Ther. 2010 Jul-Aug. 23(4):320-7. [Medline].\nClassic presentation of erythema nodosum with nodular red swellings over the shins.\nJeanette L Hebel, MD Dermatologist, Dermatology Associates of Lancaster; Dermatologist, Department of Dermatology, Lancaster General Hospital\nJeanette L Hebel, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Surgery\nDavid F Butler, MD Former Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic\nDavid F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Society for MOHS Surgery, Association of Military Dermatologists, Phi Beta Kappa\nEdward F Chan, MD Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania School of Medicine\nEdward F Chan, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, Society for Investigative Dermatology\nWilliam D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology\nDisclosure: Received income in an amount equal to or greater than $250 from: Elsevier; WebMD.\nTimothy McCalmont, MD Director, UCSF Dermatopathology Service, Professor of Clinical Pathology and Dermatology, Departments of Pathology and Dermatology, University of California at San Francisco; Editor-in-Chief, Journal of Cutaneous Pathology\nTimothy McCalmont, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, American Society of Dermatopathology, California Medical Association, College of American Pathologists, United States and Canadian Academy of Pathology\nDisclosure: Received consulting fee from Apsara for independent contractor.\nThomas Habif, MD Adjunct Professor, Department of Internal Medicine, Section of Dermatology, Dartmouth Medical School\nThomas Habif, MD is a member of the following medical societies: American Academy of Dermatology and New Hampshire Medical Society\nencoded search term (Erythema Nodosum) and Erythema Nodosum\nSubacute Nodular Migratory Panniculitis (Vilanova Disease)\nDermatologic Manifestations of Coccidioidomycosis\nPseudotuberculosis (Yersinia pseudotuberculosis Infection)\nPediatric Leprosy\nDermatologic Manifestations of Sarcoidosis\nErythema Induratum (Nodular Vasculitis)\nEfficacy and Safety of Apremilast for Behçet's Syndrome\nA Boy With Frequent Diarrhea: Differentiating IBS From IBD\nAbrupt Onset of a Tender Rash on the Upper and Lower Extremities\nCutaneous Signs of 10 Unusual Systemic Diseases\nAccording to Dermatologists\nCollagen: 'Fountain of Youth' or Edible Hoax?\nEvidence Growing That Eczema Itch More Than Skin Deep\nShingrix for Herpes Zoster: A Review\nSkin, Hair and Nail Supplements\nSunscreen Photoprotection and Vitamin D Status\nDiseases & Conditions Erythema Nodosum\n2010 thalomid-thalidomide-343211 Drugs\nDrugs thalidomide\nJournal Article Efficacy and Safety of Apremilast for Behçet's Syndrome\nDiseases & Conditions Dermatologic Manifestations of Coccidioidomycosis"