Emerging treatments

Thalidomide

Thalidomide has been used to relieve painful lesions but its use may be limited by its teratogenicity.[29][30]

Azathioprine

Azathioprine is an immunosuppressive drug that has had anecdotal success in treating erythema nodosum.[31] Thiopurine methyltransferase levels should be checked prior to initiating use, and regular monitoring of liver blood tests and full blood count are required for the duration of therapy. Patients unable to comply with regular follow-up and testing should not be given this drug.[32]

Colchicine

A widely used treatment for Behçet's syndrome, colchicine is an anti-inflammatory agent shown to be effective in controlling erythema nodosum.[33][34] Common side effects include gastrointestinal symptoms such as diarrhoea, abdominal pain, and nausea; caution should be taken when prescribing colchicine in patients with comorbidities.[35]

Dapsone

Dapsone is an antibacterial agent with anti-inflammatory properties. It has been evaluated in the management of EN recalcitrant to standard therapies; dapsone appears to be effective in the management of mucocutaneous manifestations of Behcet's disease.[36][37] Potential side effects include methemoglobinaemia, haemolysis, agranulocytosis, and peripheral motor neuropathy.[36]

Mycophenolate

Results from case reports suggest that mycophenolate may have a role as a corticosteroid-sparing agent in patients with erythema nodosum.[38][39]

Etanercept

The tumour necrosis factor (TNF)-alpha inhibitor etanercept has been used to treat EN successfully in several reported cases.[40][41]

Infliximab

Infliximab is a chimeric mouse-human monoclonal antibody that specifically binds to TNF-alpha, blocking its biological activity. This consequentially restores the ability of anergic regulatory T cells to inhibit cytokine production. Four children with Crohn's disease and refractory EN who received treatment with infliximab showed a sustained response with no adverse reactions.[42]

Ciclosporin

An immunosuppressant, ciclosporin inhibits IL-2 and other cytokines. It has been used off-label for treating inflammatory skin conditions such as atopic dermatitis, blistering disorders, and connective tissue diseases.[43] Ciclosporin has been used in EN associated with inflammatory bowel disease.[44]

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