Erythema nodosum. Clinical guidelines, photos, symptoms and treatment, the causes of

Erythema nodosum refers to pannikulita - a group of inflammatory diseases affecting the subcutaneous fatty tissue, destroying it and replacing the connective tissue. This fabric does not perform necessary functions in order to maintain full health and is substitution.

Clinical guidelines depend on whether the disease originated spontaneously or appears as a complication of the underlying disease (Primary and secondary form). The clinical picture will be different, but the common feature of education are knotted on the skin with their different localization in depth and space.

To determine the shape and specificity of diseases caused by such tumors, it is necessary a thorough diagnostic evaluation. On the basis of the diagnostic data, provided recommendations for treatment.

What is erythema nodosum

Erythema nodosum (UE) (septal panniculitis) - Disease subcutaneous fat, predominantly inflammatory nature, arising sharply. The main clinical sign will be intense erythematous painful nodes in the lower limbs, arises because of the impaired immune response to a specific antigen.

And chronic form marked erythema nodosum, which include Villanova disease (panniculitis with migration in the various areas of the body). For the first time the disease was discovered and described in 1798 English physician Robert Villani. Erythema nodosum develops suddenly, amid the general well-being.

The nodules of the same shape, painful and positioned substantially symmetrically on the body (bilateral lesions) in the knees, ankles, legs and thighs. Erythematous changes originally a bright red color, and after a few days pale (yellow-green tint).

Such nodules protrude above the level of the skin, warm to the touch.

When migrating forms of the clinical picture is different - pathologic features are identical but different localization occurring for a long time (chronic form). The histological material confirms erythema nodosum relation to a group of diseases - panniculitis, being separate form, without affecting the skin vessels.

And characteristic feature of septic panniculitis - identifying in the inflammation granulomas Miescher (histiocytes) located at the edges of the affected area. Inside the unit there is swelling and inflammation of the lobules of adipose tissue, increasing the node itself in size, causing discomfort.

Neutrophils and hemorrhage were present in the early stages of the disease, are replaced by lymphocytes and granulation tissue - the reconstruction phase.

Types of erythema nodosum

Nodular erythema subdivided into various shapes, depending on etiological factor and nature of the disease.

Erythema nodosum (Clinical recommendations are All-Russian Public Association of the Russian Federation of Rheumatology) It can be described as follows:

causative factor

Course of the disease, the severity of the pathological process and age, clinical symptoms

Primary or independent form - main disease is erythema nodosum. Secondary (dependent) form - the main symptom, concomitant diseases: hepatitis B, tuberculosis, HIV infection, fungal infections, and protozoal origin. The secondary shapes may include certain types erythema nodosum: mnogomorfnaya exudative (when cold) and erythema annulare (an allergic reaction).

Acute - occurs suddenly, accompanied by general changes (fever, chills, headaches). Nodules dense, painful, bright red, hot. Around nodules - inflammatory whisk. Marked inflammation adjacent with a bundle of joints (knee, ankle). Erythematous nodules merge to form plaques. Erosions and ulcers on the plaques are formed. After 2-3 weeks, the plaques become flat and pale. The overall clinical picture subsides. Chronic - more common in women after 45 years. Erythematous nodules with no signs of inflammation, did not rise above the level of the skin, small size. The clinical picture of quiet. Marked seasonal symptoms (disease exacerbation and subsidence). There is a second, with concomitant diseases of the pelvic organs or infection. Migrans - subacute form of the disease. Against the background of low grade fever, on the front surface of the tibia there is a single planar assembly having a center of a pale color, with a bright red periphery. Border node crisp, dense, warm, slightly painful on palpation. Node hardly above the level of the skin. After 4-7 weeks marked subsidence of the pathological process.

Stage and grade of erythema nodosum

Accepted provide 3 stage forming erythemal node:

1. The stage of maturation - formed during the first 2-7 days from the time of occurrence of the disease and is characterized by painful seal pale pink in color without clear boundaries.
2. advanced stages - the presence of bright red knot protruding above the skin, painful, hot to the touch. Around the tumors observed pastoznost soft tissue. The duration of the advanced stage - 10-14 days. The overall clinical picture of fever, chills, fatigue and pain when moving in the adjacent node joints.
3. Step resolution - blanching nodal education and the reduction of its size. On palpation - insignificant pain. Clinic subsides.

Symptoms of erythema nodosum

Erythema nodosum (clinical recommendations to patients for early detection are different from the later stages) has symptoms:

• nodular tumors, painful and warm to the touch, located in the deep layers of the skin, namely in the subcutaneous fat;
• pastoznost soft tissue around the hearth;
• eroded focal lesion borders;
• no itching;
• No predisposing factor of the node (personal injury and the presence of hemorrhage eve);
• limited growth nodes and possible merging them into plaques with a diameter of not more than 10 cm;
• nodules of dense consistency, soldered with the surrounding tissue;
• glossy surface node;
• the absence of ulcers and erosions in the tumors.

At first, the patient worried about his general condition: the body temperature rises, there is a fever, cough, fatigue. Until the moment of the formation of the basic clinical symptoms, inflamed and swollen joints neighboring node. Limited movement in these joints due to their sharp pain and swelling. Patients may confuse a clinic with symptoms of common cold.

With the advent of the characteristic nodules, usually on the front of the leg and thigh, the clinical picture is clear.

The diameter of such tumors ranges from several millimeters to several centimeters. Merging with each other, nodules form plaques. These lesions are clearly visible to the naked eye, warm to the touch and painful, with a dense texture. Most often, this clinical picture may be confused with a similar injury on the structure and flow.

Characteristic signs of erythema nodosum from other pathological conditions are:

• fast-growing nodules, reaching a certain size;
• soft tissue swelling around the hearth;
• no conventional boundaries focal lesions;
• soreness, not only to palpation, but walking in the lower extremities.

Within 2-3 weeks, the clinical picture becomes quiet, as resorption nodules. Nodular tumors change their color to a bright red color in the yellow-green color. Density and elevation above the level of the skin are reduced. Scarring at the site of resorption sites are not formed.

Causes of erythema nodosum

The etiology of erythema nodosum diverse.

Most often it is:

• bacterial infection (Tuberculosis, tularemia, brucellosis, pathogens of fever, salmonella, meningococci);
• viral disease (Hepatitis B, C, HIV, measles, chicken pox, mononucleosis, "milkmaids disease" herpes virus);
• fungal infections of the skin and mucous membranes (Sporotrichosis, aspergillosis);
• elementary (Roundworm, young forms tapeworms, toxoplasmosis, amoebas);
• influence of drugs (Anti-inflammatory, antibiotic, vaccine, sulfonamides, contraception);
• autoimmune response (Sjogren's syndrome, Behcet's, ulcerative colitis, Crohn's disease, rheumatoid arthritis);
• hormones (In pregnant while taking contraceptives);
• oncological diseases (Pancreatic cancer, acute myeloid leukemia form).

In children, a predisposing factor for the development of erythema nodosum is often a streptococcal upper respiratory tract infection.

In adults, the development of septic pannikulita in 25-44% of cases, contribute to chronic diseases, such as sarcoidosis, inflammatory bowel disease (Crohn's disease, ulcerative colitis), multiple forms of infectious diseases, rheumatic organ damage and systems.

Additional factors of erythema nodosum may be: seasonality, the stagnant venous disorders of the lower extremities, hypothermia. Based on the foregoing, nodular erythema appears frequently as a secondary disease in the background of the main.

Currently, the leading underlying disease causing septic cellulitis in adults is sarcoidosis. The incidence in different regions - 11-65%.

Against the background of sarcoidosis, erythema nodosum has several features:

• rapid increase in edema of the lower extremities (the predecessor of the appearance of nodules);
• Localization focus not on the front surface of the thigh and lower leg, and on the posterolateral side;
• large dimensions, with a diameter of at least 2 cm;
• high propensity to fusion nodules into plaques;
• expressed disorders in the bronchopulmonary system: shortness of breath, cough, chest pain.

In cancer, erythema nodosum characterized by a special resistance to therapy and are often transferred from the acute phase in chronic form, with subsequent relapses.

Septic cellulitis, while taking oral contraceptives, antibiotics and sulfonamides, occurs after 10-15 days from the start of treatment. Collecting information about the patient, should be paid to this attention.

Streptoderma changes and erythematous skin at the background of autoimmune diseases (Crohn's disease, ulcerative colitis) occur at instants exacerbation of underlying disease. Only 1/5 of all cases, the UE proceeds regardless of exacerbations.

Against the background of tubercular process, erythema nodosum is localized to the posterior surface of the tibia, in the calf muscles. Nodules are formed slowly, often ulcerate and leave behind scarring that is not specific for erythema. The frequency of - 2%.

Diagnosis of erythema nodosum

Erythema nodosum (clinical guidelines for the diagnosis dermatological diseases mainly converge) diagnosed methods:

1. Blood total confirming the presence of the inflammatory response: increase in the erythrocyte sedimentation rate (ESR), the number of leukocytes. An increase in eosinophils evidence of allergic activity of the organism (autoimmune reaction).
2. Bacterial culture from the nasopharynx and nasal cavity for the presence of pathogen streptococcus infection (more children).
3. Performing tuberculin test, if the patient is followed up by a TB specialist or has a number of signs indicating the presence of tuberculosis process (cough, fever, changes in X-rays picture).
4. Blood the number of platelets, to avoid vascular disease (thrombophlebitis of the lower limbs).
5. The capture material of nodules for detailed study and differential diagnosis.

As an additional diagnostic is conducted:

• rhinoscopy (study the nasal cavity);
• laryngoscopy (instrumental examination of the larynx);
• computed tomography (in systemic diseases and cancer);
• ultrasound diagnosis of lower extremities;
• Radiography (with bronchopulmonary pathologies);
• fecal bacterial inoculation (suspected yersiniosis).

When difficulty setting preliminary and main diagnosis or to confirm their assumptions, dermatologist refers the patient for consultation related professionals:

• vascular surgeon;
• oncologist;
• rheumatologist;
• obstetrician-gynecologist;
• pediatrician;
• infectious diseases.

If there is difficulty in the differential diagnosis of a patient during examination and blood analysis and external examination confirm the presence of an inflammatory component in the body, it is likely that erythema nodosum occurs as an independent disease.

It is therefore important to collect detailed medical history of the patient, figuring out all possible causes that contribute to the underlying disease. Diagnostic events can take place both in the community and in other cities. Dermatologist gives direction to the survey in a hospital or outside it, if suitable for this equipment is not available.

Price ultrasonography of the lower extremities, with details of all the processes will cost 900-1500 rubles. Computed tomography - 4000-6000 rubles. Consultation specialists, as well as submission of stool and blood tests, free of charge.

When to see a doctor

Clinical guidelines dermatologists are aimed at early identification of patients the first signs of emergence of erythema nodosum and early treatment in a medical facility.

In case of deterioration of the general condition (rising intoxication syndrome), with the appearance of nodules on the lower and upper limbs, painful on palpation, and hot to the touch, bright red color, should immediately contact the district physician or directly to dermatologist. To self-medicate prohibited.

Prevention of erythema nodosum

Septic cellulitis is not a life-threatening disease, but ignore its existence and not worth it. In any case, you should seek help from a doctor to rule out underlying disease, which can be a serious threat to human health.

Women and children during pregnancy, be sure to be hospitalized due to their increased sensitivity, and reduced immune response. In this category of persons, the UE is more severe than in adults. Refusal of admission or in self-employment can lead to erythema nodosum transition from the acute phase of a chronic form, reducing the chances of a full recovery.

Prevention of the underlying disease is aimed at eliminating the harmful factors that contribute to its development and includes:

• walks in the open air;
• physical activity;
• emotional tranquility;
• rejection of bad habits;
• careful care of children;
• personal hygiene, skin care.

Methods of treatment of erythema nodosum

Since erythema nodosum is often secondary, remedial measures will be aimed at addressing the underlying disease. Patients with septic panniculitis must comply with bed rest, particularly in advanced stages, because of pain and stiffness in the knee or ankle joints when moving.

The methods of treatment of erythema nodosum include:

• medication;
• traditional medicine;
• physiotherapy.

Medications

Erythema nodosum (clinical treatment recommendations include medication) is removed following medications:

1. Anti-inflammatory and analgesic therapy NSAIDs (Diclofenac 100 mg / day., Ibuprofen 1200 mg / day.) For 1-1.5 months or orally Meloxicam 15 mg / day. intramuscularly for 3 days, with the transition to oral administration of the same dose for 1 month.
2. Membrane protectors having antihypoxic and antioxidant effect. These drugs relates meksidol. Reception of 1 tablet or capsule orally 3 r / cut. The cost of packaging mexidol (30 tablets of 125 mg) - 500-800 rub.
3. Local application of anti-inflammatory ointment for faster resolution of nodes with analgesic effect. Assigned applique with 33% Dimexidum for 2 hours 1 r / d and after the application, to avoid possible dermatitis, smearing a thin layer of nimesulide-gel lesion. The duration of such procedures - 5-6 days.
4. Improvement of blood circulation, angioprotector - pentoxifylline 5 - 10 ml of intravenously, 1 r / cut, for 5-7 days.. packaging cost - 120-200 rubles.
5. Antibiotic therapy: amoxiclav 625 mg 3p / cut 10 days..
6. Antiallergic drugs: fexofenadine 180 mg / day. orally during the week.
7. In complex cases, the ineffectiveness of these agents - systemic glucocorticoids (prednisolone 5-10 mg / day orally in 1-2 months.).

Traditional methods

The most effective herbal, anti-inflammatory effect, reduces edema, are:

• broth raspberry leaves with flowers of linden, and fruits of walnut (ratio 1-1) by using as a lotion to the affected areas of the body, for 20 min., 2-3r / cut .;
• semizhilnika broth leaf, mint - in the form of lotions, 10-15 min, 2p / day..

Other methods

Possess useful properties physiotherapeutic procedures, greatly accelerating the patient recovery.

When erythema nodosum is often used:

1. Ultraviolet irradiation of the affected skin area (UVR) minimal erythemal dose for 5 days.
2. Magnetic therapy - 3-5 days.
3. Phonophoresis, with hydrocortisone ointment (to improve metabolism in the affected area of ​​skin) - 5 days.

possible complications

Weather favorable - most of all the cases ended with regression after 3-4 weeks from the date of occurrence of the first node. If the erythema nodosum is secondary, then the recovery could take up to 6 weeks.

Typically, nodules disappear. In severe cases (in the elderly, with concomitant diseases, or children), relapses and becomes chronic (often with streptococcal infections).

Erythema nodosum is not much of a threat to human health, but can affect the quality of life.

Detailed interviewing the patient, find out the cause and conducting a thorough clinical and laboratory diagnosis, you can easily put the correct diagnosis and to carry out appropriate treatment. When secondary forms of clinical guidelines, is eliminated underlying disease, which has arisen due to nodular erythema.

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