Page 133 - Journal of Special Operations Medicine - Winter 2014

Most cases of EN are classified as idiopathic, without 900mg daily for 1 month is another treatment option,
an identified cause. 1,2,4 Still, there are many associated although thyroid abnormalities are possible. Refrac-
1,2
triggers, with streptococcal infection the most common tory cases may benefit from systemic steroids once in-
infectious agent and sarcoidosis the most commonly as- fection and malignancy are excluded; oral prednisone
sociated disease. Tuberculosis has a known association has been used at a dose of 1mg/kg body weight daily.
1,2
1–3
with EN, as does pregnancy. 1,2,3 Medications, including Of note, incision and drainage is not indicated for EN;
oral contraceptives, sulfonamides, iodides, and bro- the lesions are clinically distinct from abscesses, and the
mides, have been implicated in 3% to 10% of cases. procedure is without benefit and can be harmful.
1,2
Inflammatory bowel disease is thought to be causative
in 1% to 4% of cases. Rarely (less than 1% of cases), If the diagnosis of EN is in doubt or there are other
1,2
EN may be due to other infections or to lymphoma or concerns regarding skin conditions, deployed provid-
other malignancies. 1,2 ers may utilize the Operational Teledermatology service
by e-mailing clinical photographs to derm.consult@us
.army.mil.
Clinical Course
The disease typically presents as an outcropping of ery-
thematous nodules, highly sensitive to touch. The Disclaimers
1–4
nodules vary in size from 1 to 10cm in diameter and are The views expressed in this article are those of the au-
poorly demarcated. 1,3,4 While lesions usually develop in thors and do not necessarily reflect the official policy or
a pretibial distribution, they can also form on the ex- position of the Department of the Navy, the Department
tensor surfaces of the forearms, thighs, and trunk. The of Defense, or the United States Government.
1
individual nodules can last for 2 weeks, with new le-
sions forming for up to 6 weeks. They do not ulcerate,
1
and tend to heal completely in 1 to 2 months without Disclosures
atrophy or scarring. 1,3,4 A prodrome may occur as early The authors have nothing to disclose.
as 1 to 3 weeks before the onset, characterized by fever,
cough, malaise, weight loss, and arthralgias. 1,3,4
References
The diagnosis of EN is generally clinical, with biopsy 1. Schwartz RA, Nervi SJ. Erythema nodosum: a sign of sys-
reserved for atypical cases. The differential diag- temic disease. Am Fam Physician. 2007;75:695–700.
1,2
nosis includes other varieties of panniculitis, such as 2. Lebwohl MG, Heymann WR, Berth-Jones J, Coulson I.
α -antitrypsin deficiency, erythema induratum, lupus Treatment of skin disease: comprehensive therapeutic strat-
1
egies. 3rd ed. Maryland Heights, MO: Mosby; 2010.
profundus, and nodular fat necrosis. 1,3,4 Given the nu- 3. Requena L, Yus ES. Panniculitis. Part I. Mostly septal pan-
merous associations with underlying systemic disease niculitis. J Am Acad Dermatol. 2001;45:163–183.
and the development of EN, the first step is a compre- 4. Mert A, Ozaras R, Tabak F, et al. Erythema nodosum: an ex-
hensive history and physical examination. Laboratory perience of 10 years. Scand J Infect Dis. 2004;36:424–427.
evaluation should include complete blood count with
differential, pregnancy testing for females, and erythro-
cyte sedimentation rate or C-reactive protein levels. 1,3,4
Investigation for streptococcal infection (i.e., throat LT Vigilante is a 2009 graduate of Loyola University Chi-
culture, antistreptolysin-O titer) is appropriate, as is cago Stritch School of Medicine. He completed a transitional
chest radiography to screen for sarcoidosis and purified internship at Naval Medical Center Portsmouth and training
protein derivative for tuberculosis. If the patient com- and certification as an undersea and diving medical officer in
1–4
plains of gastrointestinal symptoms or diarrhea, then 2010, and has since been assigned to the Captain James A.
stool should be assessed, and an evaluation for inflam- Lovell Federal Health Care Center. E-mail: john.vigilante@
matory bowel disease could be considered. 1,3,4 med.navy.mil.

LCDR Scribner graduated from Albany Medical College in
Treatment 2005, and then completed an obstetrics and gynecology in-
ternship at Naval Medical Center San Diego. She then served
The disease tends to be self-limited, with a general ap- as the medical officer for the USS Cleveland (LPD-7) and then
proach of supportive care and treatment of any under- Expeditionary Health Services Pacific before completing her
lying disorders. Follow-up should continue until the residency in dermatology at Naval Medical Center San Diego
1–4
lesions resolve and associated conditions, if any, are ade- in 2013. She is currently stationed at the Captain James A.
quately treated. Nonsteroidal anti-inflammatory drugs, Lovell Federal Health Care Center, where she serves as the sec-
including naproxen and indomethacin, have proved ef- tion chief of dermatology and a staff dermatologist.
fective. Oral potassium iodide with a dose of 400 to
1,2

Erythema Nodosum 123