Erythema nodosum
- Overview
- Theory
- Diagnosis
- Management
- Follow up
- Resources
Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
mild to moderately severe symptoms
bed rest and leg elevation + non-steroidal anti-inflammatory drugs + treatment of underlying cause
EN almost always resolves spontaneously.
The main task of the physician is to identify and treat the underlying cause.
In most cases, bed rest, elevation of legs, and symptomatic relief are the only treatments required. Risk of deep vein thrombosis should be assessed and compression stockings used if necessary.
analgesia
Additional treatment recommended for SOME patients in selected patient group
Should be given for symptomatic relief for 7 to 10 days if joint pains are severe or if eruption recurs.[27]Friedman ES, LaNatra N, Stiller MJ. NSAIDs in dermatologic therapy: review and preview. J Cutan Med Surg. 2002 Sep-Oct;6(5):449-59. http://www.ncbi.nlm.nih.gov/pubmed/12202973?tool=bestpractice.com
Non-steroidal anti-inflammatory drugs (NSAIDs) and aspirin are generally preferred but are contraindicated in patients with a history of gastrointestinal bleeding; paracetamol may be used in these patients, but may be less effective as an analgesic agent.
Primary options
aspirin: 300-900 mg orally every 4-6 hours when required, maximum 4000 mg/day
OR
ibuprofen: 400-800 mg orally every 4-6 hours when required, maximum 2400 mg/day
OR
naproxen: 250-500 mg orally twice daily when required, maximum 1250 mg/day
OR
indometacin: 25-50 mg orally every 8-12 hours when required, maximum 200 mg/day
Secondary options
paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day
potassium iodide
In more severe cases and in those patients who do not respond to initial therapy, oral potassium iodide has been used successfully.
The mechanism is unclear. Potassium affects neutrophil chemotaxis and chemotoxicity.[23]Sterling 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. http://www.ncbi.nlm.nih.gov/pubmed/11004629?tool=bestpractice.com It also has an antifungal effect.[28]Schultz E, Whiting D. Treatment of erythema nodosum and nodular vasculitis with potassium iodides. Br J Dermatol. 1976 Jan;94(1):75-8. http://www.ncbi.nlm.nih.gov/pubmed/943168?tool=bestpractice.com
As hypothyroidism due to iodide intake has been described, thyroid function should be monitored in cases of long-term use. Hyperkalaemia is also a potential side effect.
If there is no response after 2 weeks, consider a corticosteroid if not contraindicated.
Primary options
potassium iodide: 300 mg (6 drops) orally three times daily
More potassium iodideDose refers to supersaturated solution. May also be available in other formulations.
analgesia
Additional treatment recommended for SOME patients in selected patient group
Non-steroidal anti-inflammatory drugs (NSAIDs) and aspirin are generally preferred but are contraindicated in patients with a history of gastrointestinal bleeding; however, paracetamol may be less effective as an analgesic agent.
Primary options
aspirin: 300-900 mg orally every 4-6 hours when required, maximum 4000 mg/day
OR
ibuprofen: 400-800 mg orally every 4-6 hours when required, maximum 2400 mg/day
OR
naproxen: 250-500 mg orally twice daily when required, maximum 1250 mg/day
OR
indometacin: 25-50 mg orally every 8-12 hours when required, maximum 200 mg/day
Secondary options
paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day
intralesional corticosteroid injection
Indicated for persistent painful nodules.
Potentially limited by procedural discomfort.
Primary options
triamcinolone acetonide: consult specialist for guidance on intralesional dose
analgesia
Additional treatment recommended for SOME patients in selected patient group
Should be given for symptomatic relief for 7 to 10 days if joint pains are severe or the eruption recurrent.[27]Friedman ES, LaNatra N, Stiller MJ. NSAIDs in dermatologic therapy: review and preview. J Cutan Med Surg. 2002 Sep-Oct;6(5):449-59. http://www.ncbi.nlm.nih.gov/pubmed/12202973?tool=bestpractice.com
Non-steroidal anti-inflammatory drugs (NSAIDs) and aspirin are generally preferred but are contraindicated in patients with a history of gastrointestinal bleeding; however, paracetamol may be less effective as an analgesic agent.
Primary options
aspirin: 300-900 mg orally every 4-6 hours when required, maximum 4000 mg/day
OR
ibuprofen: 400-800 mg orally every 4-6 hours when required, maximum 2400 mg/day
OR
naproxen: 250-500 mg orally twice daily when required, maximum 1250 mg/day
OR
indometacin: 25-50 mg orally every 8-12 hours when required, maximum 200 mg/day
Secondary options
paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day
systemic corticosteroids
Treatment recommended for ALL patients in selected patient group
The erythema nodosum migrans variant is uncommon; however, when present, or in severe or recalcitrant cases, a short course of systemic corticosteroids may be indicated.
Primary options
prednisolone: 20 mg orally once daily for 7-10 days
severe refractory symptoms
systemic corticosteroids + treatment of underlying cause
Indicated in more severe cases of intolerable pain and systemic manifestations of fever, body ache, and malaise. However, relative and absolute contraindications to systemic corticosteroids should be carefully considered. Corticosteroids should only be administered if an underlying cause for erythema nodosum has been investigated and underlying infection or malignancy can be ruled out.
Dose should be reduced gradually over 2 to 4 weeks.
Treatment of the underlying cause should continue.
Primary options
prednisolone: 5-60 mg orally once daily in the morning
bed rest and leg elevation
Treatment recommended for ALL patients in selected patient group
Bed rest and elevation of legs can be used for symptomatic relief. Risk of deep vein thrombosis should be assessed and compression stockings used if appropriate.
analgesia
Additional treatment recommended for SOME patients in selected patient group
Should be given for symptomatic relief for 7 to 10 days if joint pains are severe or the eruption recurrent.[27]Friedman ES, LaNatra N, Stiller MJ. NSAIDs in dermatologic therapy: review and preview. J Cutan Med Surg. 2002 Sep-Oct;6(5):449-59. http://www.ncbi.nlm.nih.gov/pubmed/12202973?tool=bestpractice.com
Non-steroidal anti-inflammatory drugs (NSAIDs) and aspirin are generally preferred but are contraindicated in patients with a history of gastrointestinal bleeding; however, paracetamol may be less effective as an analgesic agent
Primary options
aspirin: 300-900 mg orally every 4-6 hours when required, maximum 4000 mg/day
OR
ibuprofen: 400-800 mg orally every 4-6 hours when required, maximum 2400 mg/day
OR
naproxen: 250-500 mg orally twice daily when required, maximum 1250 mg/day
OR
indometacin: 25-50 mg orally every 8-12 hours when required, maximum 200 mg/day
Secondary options
paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day
Choose a patient group to see our recommendations
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
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