Erythema Nodosum: A Practical Approach and Diagnostic Algorithm

Daniela Michelle Pérez-Garza; Sonia Chavez-Alvarez; Jorge Ocampo-Candiani; Minerva Gomez-Flores

Disclosures

Am J Clin Dermatol. 2021;22(3):367-378. 

In This Article

Treatment

Therapy options are summarized in Table 4. Symptomatic support is an adequate approach for most patients. Compression bandages and limb elevation may be used for edema and pain relief.[67] Non-steroidal anti-inflammatory drugs, such as indomethacin at 100–150 mg/day or naproxen 500 mg/day, may be used for pain control.[68,69] Caution should be taken with the use of non-steroidal anti-inflammatory drugs in patients with IBD as these drugs may worsen IBD symptoms.[70]

In refractory disease, oral potassium iodide may be used with a dose of 300–900 mg daily divided into three doses and tapered to 150 mg/day.[71,72] Although it has been used for a long time with a good response rate,[73,74] a recent study showed low improvement and suggested that its potential efficacy in inflammatory skin disorders is overestimated.[72] The exact mechanism by which potassium iodide exerts its anti-inflammatory effect is unknown. The anti-inflammatory effects are due to increases in IL-10 and IL-35 levels[75] and the suppression of chemotaxis in neutrophils and their capability to generate toxic radicals.[76] Common acute side effects are diarrhea, nausea, vomiting, and stomach pain. Symptoms of iodism or potassium toxicity may appear with prolonged use. It is contraindicated during pregnancy or while breastfeeding.[77]

Colchicine at 1–2 mg/day, adjusted to body weight, has been used mainly in patients with EN and Behçet disease.[78–80] It decreases neutrophil chemotaxis and degranulation. Common side effects are gastrointestinal symptoms (diarrhea, abdominal pain, and nausea).[81]

Dapsone inhibits neutrophil myeloperoxidase and neutrophil chemotaxis. Doses of 50–75 mg/day have been used with caution because of its potential side effects, including methemoglobinemia, hemolysis, agranulocytosis, and peripheral motor neuropathy.[82] Potassium iodide, colchicine, and dapsone are drugs used for treating neutrophilic dermatosis, making them a good option for EN associated with Bechet disease.

Systemic and intralesional corticosteroids are rarely used to treat EN. Prednisone 40 mg/day has been used in severe conditions. For recalcitrant nodules, intralesional triamcinolone acetonide 5 mg/mL, injected to the center of an inflamed lesion, has been used. An underlying infection or malignancy should be ruled out before using corticosteroids.[10]

Some patients respond to hydroxychloroquine 200 mg twice daily.[83,84] Tetracyclines, such as minocycline 100 mg twice daily and tetracycline 500 mg every 6–12 h, have been considered as an option for chronic EN.[85,86] Tumor necrosis factor-α inhibitors such as etanercept,[87,88] adalimumab,[89,90] and infliximab[91,92] have been used in patients with recalcitrant disease. Thalidomide and cyclosporine A have been used in EN associated with IBD.[9,28]

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