Presentation on theme: "Medical Student Core Curriculum in Dermatology"— Presentation transcript:
1 Medical Student Core Curriculum in Dermatology Erythema NodosumMedical Student Core Curriculumin DermatologyLast updated March 23, 2011
2 Modules InstructionsThe following module contains a number of blue, underlined terms which are hyperlinked to the dermatology glossary, an illustrated interactive guide to clinical dermatology and dermatopathology.We encourage the learner to read all the hyperlinked information.
3 Goals and ObjectivesThe purpose of this module is to help medical students develop a clinical approach to the evaluation and initial management of patients presenting with erythema nodosum.By completing this module, the learner will be able to:Identify and describe the morphology of erythema nodosumName conditions associated with erythema nodosumRecommend an initial treatment plan for a patient with erythema nodosumDiscuss when to refer to a patient with erythema nodosum to a dermatologist
5 Case One: HistoryHPI: Mrs. Mosely is a 35-year-old woman who presents to her primary care physician with tender red “bumps” on her anterior shins. The lesions appeared over the course of a few days and have started to resolve with faint bruises remaining. She also reports a recent history of a sore throat and fever two weeks ago, which improved after a course of antibiotics.PMH: no major illness or hospitalizationsMedications: none aside from recent antibiotic courseAllergies: noneFamily history: noncontributorySocial history: lives with husband and 12-year-old child who also had a sore throatHealth-related behaviors: no tobacco, alcohol, or drug useROS: no cough or rhinorrhea
6 Case One: Exam Vital signs: normal Gen: well-appearing HEENT: normal Skin: multiple scattered shiny, red nodules on the anterior shins bilaterally
7 Case One, Question 1 What is the appropriate next step? Anti-Streptolysin O titerBiopsy the lesionDrain the nodulesTopical steroid ointment
8 Case One, Question 1 Answer: a What is the appropriate next step? Anti-Streptolysin O titerBiopsy the lesion (diagnosis can be made clinically)Drain the nodules (lesions are more inflammatory vs. abscess)Topical steroid (not effective)
9 Diagnosis: Erythema Nodosum Mrs. Mosely’s recent history of sore throat and fever is suggestive of acute pharyngitis. Her ASO titer came back elevated.The lesions on her legs were diagnosed as erythema nodosum.
10 Erythema Nodosum (EN)Characterized by the presence of painful, erythematous, non-ulcerative nodulesOften symmetric distribution, located bilaterally below the knees (mainly on the anterior tibial surface)Lesions evolve from bright red to brown-yellow, resembling old ecchymosesOld and new lesions often coexistPatients may also present with fever, fatigue, and arthralgiasThe morphology of the lesion, a deep nodule, identifies EN as an inflammatory disease of the fat (called a panniculitis)
11 Case One, Question 2Which of the following history and clinical items are commonly found in patients with EN?Patient is femaleRecent feverRecent upper respiratory infectionUse of oral contraceptivesAll of the above
12 Case One, Question 2 Answer: e Which of the following history and clinical items are commonly found in patients with EN?Patient is femaleRecent feverRecent upper respiratory infectionUse of oral contraceptivesAll of the above
13 EN: The BasicsCan occur at any age, but most cases appear between 2nd and 4th decades15-20x more common in women than menEN is not a disease, but a reaction pattern to a variety of factors including infections, medications, and systemic diseasesDiagnosis of EN should always be followed by a search for the underlying etiologyStreptococcal disease is the most common cause of EN in childrenDrugs, sarcoidosis, and inflammatory bowel disease (IBD) are commonly associated disorders in adults with EN
14 Conditions Associated with EN Idiopathic > 50%InfectionsStreptococcal infections, tuberculosis, histoplasmosis, coccidiomycosisDrugsOral contraceptive pills, sulfonamidesNeoplasmsLymphoma, leukemia, renal cell carcinomaMiscellaneous ConditionsSarcoidosis, inflammatory bowel diseaseNote: Only a few common causes of EN are mentioned. EN is associated with a wide variety of disease processes and medications.
15 Case One, Question 3Which of the following statement regarding treatment of EN is true?Antihistamines are often used for treatmentAnti-inflammatories should be avoidedEN tends to be self-limitedSystemic steroids are of no value
16 Case One, Question 3 Answer: c Which of the following statement regarding treatment of EN is true?Antihistamines are often used for treatment (Not true)Anti-inflammatories should be avoided (Not true. Anti- inflammatories are often used in the treatment of EN)EN tends to be self-limitedSystemic steroids are of no value (Not true. Systemic steroids can be used if underlying infection and malignancy have been excluded)
17 EN: TreatmentEN is usually self-limited or resolves with treatment of the underlying disorderLesions heal without atrophy or scarringEruption generally lasts from 3 to 6 weeks, and recurrences are frequentTreatment is typically symptomaticSupportive measures and pain control are recommendedThe use of systemic glucocorticoids should be weighed against the possibility of masking an underlying neoplastic, inflammatory, or infectious conditionOral potassium iodide therapy is another treatment option
19 Case Two: HistoryHPI: Ms. Prescott is a 35-year-old woman who presents to her primary care provider with tender red nodules on her anterior shins. Some of the lesions appear to be resolving, but others are still appearing. No sick contacts or anyone else with a rash.PMH: no major illnesses or hospitalizationsAllergies: noneMeds: oral contraceptive pills (unable to recall the name)Family history: father with history of BCCSocial history: lives with a friend in an apartment, works in advertisingHealth-related behaviors: alcohol use (1-2 drinks per week), no tobacco or drug useROS: negative’
20 Case Two: Exam Vital Signs: normal HEENT: normal exam Lungs: clear to auscultationSkin: multiple scattered shiny, erythematous nodules on the anterior lower extremities
21 Case Two, Question 1The primary care provider suspects erythema nodosum. What else should be considered as part of the initial evaluation?Make sure a thorough medical history and review of systems was performedOrder an ASOPlace a PPDAll of the above
22 Case Two, Question 1 Answer: d The primary care provider suspects erythema nodosum. What else should be considered as part of the initial evaluation?Make sure a thorough medical history and review of systems was performedOrder an ASOPlace a PPDAll of the above
23 Case Two, Question 2What is the likely cause of Ms. Prescott’s erythema nodosum?Crohn’s diseaseOral contraceptivesSarcoidosisTuberculosis
24 Case Two, Question 2 Answer: b What is the likely cause of the Ms. Prescott’s erythema nodosum?Crohn’s disease (Possible that EN is the presenting feature of IBD, but her OCP use is a more likely cause in this case)Oral contraceptivesSarcoidosis (Possible, but less likely)Tuberculosis (No known risk factors, but a PPD placement would be prudent)
26 Case Three: HistoryHPI: Ms. Ojeda is a 50-year-old woman who presents to the general medicine clinic with tender red nodules on her posterior calves for the past 2 months.PMH: last visit to the doctor was 10 years ago, no major illnesses or hospitalizationsMedications: noneAllergies: noneFamily history: mother with hypertensionSocial history: lives with multiple family members in the city, recently moved to the US from GuatemalaHealth-related behaviors: no tobacco, alcohol, or drug useROS: occasional fatigue
27 Case Three: Exam Vital signs: normal Physical exam normal except for: tender erythematous shiny nodules on the posterior calves bilaterally
28 Case Three, Question 1 What is the most likely diagnosis? Erythema induratumErythema nodosumPolyarteritis nodosaSyphilitic gumma
29 Case Three, Question 1 Answer: a What is the most likely diagnosis? Erythema induratumErythema nodosum (Characterized by painful, erythematous, non-ulcerative nodules usually located on anterior lower legs)Polyarteritis nodosa (Characterized by painful, subcutaneous nodules. Livedo reticularis may be present)Syphilitic gumma (Painless subcutaneous nodules, enlarge, attach to the overlying skin, and eventually ulcerate)
30 Erythema InduratumErythema induratum is a panniculitis characterized by tender subcutaneous nodules usually located on the lower posterior calfErythema induratum is chronic and more commonly affects middle-aged womenOccurs in the setting of tuberculosis (latent)PPD will usually be positiveLesions can resolve spontaneously with or without ulceration and often heal with scarring
31 When to Biopsy Panniculitis For persistent lesions (> 6wks) or when the diagnosis is unclear a biopsy is typically necessary and these patients should be referred to a dermatologistA deep incisional or excisional biopsy should be obtained for best visualization because a punch biopsy is likely to produce an inadequate sample
32 Take Home PointsEN is characterized by painful, erythematous, non- ulcerative subcutaneous nodules.Most cases appear between the 2nd and 4th decade of life and is more common in women.There are numerous etiologies for EN including infections, medications, neoplasms, and other miscellaneous conditions.Streptococcal infection is the most common etiologic factor in children.
33 Take Home PointsDrugs, sarcoidosis, systemic fungal infections (coccidiomycosis, histoplasmosis) and inflammatory bowel disease are commonly associated disorders in adults with EN.EN tends to be self-limited or resolves with treatment of the underlying disorder.Erythema induratum can be distinguished from EN by the chronic time course, location on the posterior calf, ulceration of the lesions and association with latent tuberculosis.
34 AcknowledgementsThis module was developed by the American Academy of Dermatology Medical Student Core Curriculum Workgroup fromPrimary authors: Sarah D. Cipriano, MD, MPH; Eric Meinhardt, MD; Timothy G. Berger, MD, FAAD.Peer reviewers: Peter A. Lio, MD, FAAD; Carlos Garcia, MD.Revisions and editing: Sarah D. Cipriano, MD, MPH; Jillian W. Wong. Last revised March 2011.
35 ReferencesBerger T, Hong J, Saeed S, Colaco S, Tsang M, Kasper R. The Web-Based Illustrated Clinical Dermatology Glossary. MedEdPORTAL; Available from:Bolognia Jean L, Braverman Irwin M, "Chapter 54. Skin Manifestations of Internal Disease" (Chapter). Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, Loscalzo J: Harrison's Principles of Internal Medicine, 17e:James WD, Berger TG, Elston DM, “Chapter 16. Mycobacterial Disease” (chapter). Andrews’ Diseases of the Skin Clinical Dermatology. 10th ed. Philadelphia, Pa: Saunders Elsevier; 2006: 337.James WD, Berger TG, Elston DM, “Chapter 23. Diseases of Subcutaneous Fat” (chapter). Andrews’ Diseases of the Skin Clinical Dermatology. 10th ed. Philadelphia, Pa: Saunders Elsevier; 2006:Requena L, Yuz ES. Erythema Nodosum. Semin Cutan Med Surg. 2007;26: Requena Luis, Yus Evaristo S, Kutzner Heinz, "Chapter 68. Panniculitis" (Chapter). Wolff K, Goldsmith LA, Katz SI, Gilchrest B, Paller AS, Leffell DJ: Fitzpatrick's Dermatology in General Medicine, 7e:Schwartz RA, Nervi SJ. Erythema Nodosum: A Sign of Systemic Disease. Am Fam Physician ;75:Wolff K, Johnson RA, "Section 7. Miscellaneous Inflammatory Disorders" (Chapter). Wolff K, Johnson RA: Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology, 6e: