Erythema nodosum: causes and treatments

Healthylife Pharmacy17 July 2018|3 min read

Erythema nodosum (EN) is a specific form of panniculitis – inflammation of the fat located under the skin It often occurs with other infections, such as bacterial or viral infections, as a side effect of taking medication, or from some diseases. It is presumed to be a delayed hypersensitivity reaction.

EN is described as tender, palpable nodules of red or violet appearance occurring usually along the shins or lower extremities but may occur anywhere there is fat under the skin, including the thighs, arms, trunk, face and neck. The nodules may range from 1 to 5 cm and can often join to form a hardened area. Over time, a bruise-like effect may be seen. Fever, malaise and arthralgias (aching joints) may occur simultaneously. Resolution usually takes place between a 2 to 8-week period, leaving no scarring.

EN occurs more often between the ages of 20 and 40 and in females more than males, but may occur at any time to anybody.

Why erythema nodosum develops is unclear, but an association with a reaction of the immune system is suspected due to its frequent appearance with other disorders.

Common disorders associated with erythema nodosum

Streptococcal infection - bacterial infection found in illnesses such as pharyngitis, skin infections, sepsis and endocarditis. This is common in children.

Sarcoidosis – an inflammatory disorder involving abnormal collections of inflammatory cells that form lumps known as granulomas. These usually begin in the skin, lungs, and lymph nodes, but any organ of the body may be involved. The cause of sarcoidosis is unknown.

Inflammatory bowel disease – a relapsing and remitting disorder that affects various sites of the bowel, causing diarrhoea and abdominal pain. Inflammation results from a cell-mediated immune response from the mucosa of the bowel. Crohn’s disease and ulcerative colitis are examples of inflammatory bowel disease.

Hormones – it tends to affect females more than males aged between 20 – 40. This could be due to the role that female sex hormones play in the modulators of the immune system. Pregnancy, perimenopause, menopause and contraception may cause changes in the hormonal system. An efficient hormonal system may help alleviate occurrences of erythema nodosum and other symptoms of hormonal imbalances. 

Other possible erythema nodosum causes include:

  • Other bacterial infections (yersinia, salmonella, mycoplasma, chlamydia, lymphogranuloma venereum)
  • Fungal infections (kerion, coccidioidomycosis, blastomycosis, histoplasmosis).
  • Rickettsia infections – caused by bacteria transmitted by a bite from infected host insects such as fleas or ticks. In Australia, infections include Queensland tick typhus, Flinders Island spotted fever, scrub typhus and murine typhus
  • Viral infections (such as Epstein-Barr or hepatitis B)
  • Medications such as sulfonamides, iodides, bromides and oral contraceptives
  • Cancer
  • Behçet disease (inflammatory disorder affecting multiple parts of the body)
  • TB

Up to one-third of cases of erythema nodosum are of unknown cause.

Diagnosing erythema nodosum

The skin often serves as an indicator of underlying internal disorders/diseases. Meaning what you see on the outside may be connected to conditions affecting the internal body. Treating only the external visual condition may not be enough to resolve the condition.

Diagnosis is by clinical evaluation and medical history. A biopsy may be performed on the fatty layer of the skin to confirm the diagnosis – septal panniculitis (inflammation of the septae dividing the fat into lobules). 

Your healthcare professional may then do a number of tests to determine the underlying cause – infection, markers for inflammation or auto-immune diseases.

Erythema nodosum treatments 

Treatment is based on the cause – if known. Compression stockings and leg elevation are suggested, along with prescribed anti-inflammatory and pain-relieving medication.

In most cases, erythema nodosum lesions will resolve within 2-6 weeks, but there may be some residual swelling and leg pain.

Erythema nodosum should be diagnosed by a healthcare professional, and causes identified to rule out other medical concerns. Complementary therapies aim to support general health but should always be used with your healthcare professional’s knowledge.

Some suggestions for erythema nodosum natural treatments include:

Zinc

Zinc is an essential micronutrient that regulates immune responses. Deficiency may lead to immune dysfunctions and poor response to bacterial infection and sepsis. Zinc deficiency also plays a role in inflammation by elevating inflammatory response (inflammation and poor wound healing). Zinc is an integral part of the cell membrane of the epidermal and dermal tissues (the skin). It is responsible for healthy skin cell membranes and supports wound healing. Zinc protects the skin from antioxidant damage. It can be taken internally if deficiency is suspected and applied topically to help wound healing.

Vitamin D

Vitamin D has been shown to have a regulatory role in the immune system function. A blood test from your healthcare professional can evaluate if vitamin D levels are adequate and suggest supplementation if necessary.

Turmeric/curcumin

Numerous studies have demonstrated curcumin has anti-inflammatory, anticancer, antioxidant and anti-microbial properties.

Aloe vera
This may help reduce inflammation when applied topically to affected areas of the skin.

Goldenseal (Hydrastis canadensis)
Used for infections, including those causing skin lesions.

Supplements should only be used under the guidance of a healthcare professional, as some may interact with pharmaceutical medications or not be appropriate in some disease conditions.

Related reading:

References:

  1. Healthdirect Australia. (n.d.-c). Erythema nodosum. Symptoms, Causes, Diagnosis and Treatment | Healthdirect. https://www.healthdirect.gov.au/erythema-nodosum 
  2. https://www.dermcoll.edu.au/atoz/erythema-nodosum/ 
  3. Erythema nodosum. https://www.ncbi.nlm.nih.gov/pubmed/30269303
  4. https://www.msdmanuals.com/en-au/professional/pulmonary-disorders/sarcoidosis/sarcoidosis 
  5. https://www.msdmanuals.com/en-au/professional/dermatologic-disorders/hypersensitivity-and-inflammatory-skin-disorders/erythema-nodosum 
  6. Erythema nodosum – review of the literature https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4918048/
  7. https://www.msdmanuals.com/en-au/professional/gastrointestinal-disorders/inflammatory-bowel-disease-ibd/overview-of-inflammatory-bowel-disease 
  8. https://www.msdmanuals.com/en-au/professional/dermatologic-disorders/hypersensitivity-and-inflammatory-skin-disorders/erythema-nodosum 
  9. https://www.stlukes-stl.com/health-content/medicine/33/000154.htm 
  10. Zinc in Infection and Inflammation https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5490603/
  11. Jeon, H. C., Choi, M., Paik, S. H., Na, S. J., Lee, J. H., & Cho, S. (2011). A case of assisted reproductive therapy-induced erythema nodosum. Annals of Dermatology, 23(3), 362. https://doi.org/10.5021/ad.2011.23.3.362
  12. Gammoh, N. Z., & Rink, L. (2017). Zinc in infection and inflammation. Nutrients, 9(6), 624. https://doi.org/10.3390/nu9060624
  13. Ao, T., Kikuta, J., & Ishii, M. (2021). The effects of vitamin D on immune system and inflammatory diseases. Biomolecules, 11(11), 1624. https://doi.org/10.3390/biom11111624
  14. Hewlings, S., & Kalman, D. (2017). Curcumin: A review of its Effects on Human health. Foods, 6(10), 92. https://doi.org/10.3390/foods6100092
  15. Sánchez, M., González-Burgos, E., Iglesias, I., & Gómez-Serranillos, M. P. (2020). Pharmacological Update Properties of Aloe Vera and its Major Active Constituents. Molecules, 25(6), 1324. https://doi.org/10.3390/molecules25061324
  16. Mandal, S. K., Maji, A. K., Mishra, S., Ishfaq, P. M., Devkota, H. P., Sanches-Silva, A., & Das, N. (2020). Goldenseal (Hydrastis canadensis L.) and its active constituents: A critical review of their efficacy and toxicological issues. Pharmacological Research, 160, 105085. https://doi.org/10.1016/j.phrs.2020.105085
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