Erythema nodosum

Healthylife Pharmacy|17 July 2018|3 min read

Common disorders associated with erythema nodosum
Diagnosing Erythema nodosum
Treatment
Naturopathic considerations

Erythema nodosum (EN) is a specific form of panniculitis – (inflammation of the fat located under the skin) which may result from a number of provocative factors. It often occurs with other infections such as bacterial or viral infections; from medication; or from some diseases. It is presumed to be a delayed hypersensitivity reaction.

EN is described as tender, palpable nodules of red or violet appearance occurring usually along the shins or lower extremities, but can occur anywhere there is fat under the skin, including the thighs, arms, trunk, face and neck. The nodules may range in size from 1 to 5 cm and can often join to form a hardened area. Over time a bruise-like effect may be seen. Fever, malaise and arthralgias (aching joints) may occur at the same time. Resolution usually takes place between a 2 to 8-week period leaving no scaring.

EN occurs more often between the ages of 20 and 40 and in females more than males, but can occur at any time to anybody.

Why erythema nodosum develops is unclear but association with a reaction of the immune system is suspected due to its frequent appearance with other disorders.

Common disorders associated with erythema nodosum

Streptococcal infection - bacterial infection found in illnesses such as pharyngitis, skin infections, sepsis and endocarditis. This is common in children.

Sarcoidosis – an inflammatory disorder involving abnormal collections of inflammatory cells which form lumps known as granulomas. These usually begin in the skin, lungs, lymph nodes, but any organ of the body can be involved. The cause of sarcoidosis is unknown.

Inflammatory bowel disease – a relapsing and remitting disorder which affects various sites of the bowel causing diarrhoea and abdominal pain. Inflammation results from a cell-mediated immune response from the mucosa of the bowel. Crohn’s disease and ulcerative colitis are examples of inflammatory bowel disease.

Hormones. Why females more than males and aged between 20 – 40. This could be due to the role which female sex hormones play in the modulators of the immune system. Pregnancy, peri menopause, menopause and contraception may cause changes in the hormonal system. An efficient hormonal system can may help to alleviate occurrences of erythema nodosum along with other symptoms of hormonal imbalances.

Environmental sensitivities. These may be implicated in idiopathic cases of erythema nodosum. Chemical exposure is implicated in endocrine disorders – such as hormonal dysfunction. BPA is a chemical used in the production of plastics and epoxy resin and has been implicated in many disease conditions of the body. Reducing or avoiding potential endocrine disruptors may not only alleviate erythema nodosum but also conditions associated with the disease. Endocrine dysrubtors include plastics used in cooking and food preparation; tin food; plastic water bottles; natural food chemicals such as phytates and topical cosmetics, as some examples.

Other possible activating causes include:

Other bacterial infections (Yersinia, Salmonella, mycoplasma, chlamydia, lymphogranuloma venereum)
Fungal infections (kerion, coccidioidomycosis, blastomycosis, histoplasmosis).
Rickettsia infections – caused by bacteria transmitted by a bite from infected host insects such as flea or tick. In Australia infection include Australia Queensland tick typhus, Flinders Island spotted fever, scrub typhus and murine typhus.
Viral infections (such as Epstein-Barr or hepatitis B).
Medications such as sulfonamides, iodides, bromides and oral contraceptives
Cancers
Behçet disease (inflammatory disorder affecting multiple parts of the body)
TB

Up to one third of cases of Erythema nodosum are of unknown cause.

Diagnosing Erythema nodosum

The skin often serves as an indicator of underlying internal disorders/diseases. Meaning what you see on the outside can be connected to conditions affecting the internal body. Treating only the external, visual condition may not be enough to resolve the condition.

Diagnosis is by clinical evaluation and medical history. A biopsy may be performed on the fatty layer of the skin to confirm diagnosis – septal panniculitis (inflammation of the septae dividing the fat into lobules).

The doctor may then do a number of tests to determine the underlying cause – infection, markers for inflammation, auto-immune diseases etc.

Treatment

Treatment is based on the cause – if known. Compression stockings and leg elevation are suggested along with prescribed anti-inflammatory and pain relieving medication.

In most cases for most people, erythema nodosum lesions will resolve within 4-6 weeks but there may be some residual swelling and leg pain.

Erythema nodosum should be diagnosed by a medical practitioner and causes identified to rule out other medical concerns. Complementary therapies aim to support the general health of the body, but should always be used with your physician’s knowledge.

Naturopathic considerations

Complementary therapies aim to help to:

Reduce inflammation – depending on causes (digestive dysfunction for example).
Enhance immunity to support immune function and prevent infections – this may include nutritional and herbal intervention, sleep and stress management strategies.
Optimamize hormonal system function (this can take a few months under the care of a naturopath)
Detoxification support for the eliminatory pathways of the body – skin, bowel, liver and kidney.
Food sensitivity and intolerance identification and removal from diet

Some suggestions include:

Zinc

Zinc is an essential micronutrient that is involved in the regulation of immune responses. Deficiency can lead to immune dysfunctions and poor response to bacterial infection and sepsis. Zinc deficiency also plays a role in inflammation, by elevating inflammatory response (inflammation and poor wound healing). Zinc is an integral part of in the cell membrane of the epidermal and dermal tissues (the skin). It is responsible for healthy skin cell membranes and supports wound healing. Zinc protects skin from antioxidant damage. It can be taken internally if deficiency is suspected and also applied topically to help wound healing.

Vitamin D

Vitamin D has been shown to have a regulatory role in the immune system function. A blood test from your doctor can evaluate if vitamin D levels are adequate and suggest supplementation if necessary.

Turmeric/curcumin

Numerous animal and laboratory studies have demonstrated curcumin has anti-inflammatory, anticancer, antioxidant and anti-microbial properties.

Aloe vera. The herb is effective in reducing inflammation when applied topically to affected areas of the skin.

Goldenseal (Hydrastis canadensis). Used for infections, including those causing skin lesions.

Probiotics

Often the first consideration is the gut. Probiotics can help with so many disorders from the inside such as skin barrier function, immune support, digestive health, inflammation, toxic elimination, for example. Just add fibre for prebiotic support (psyllium, slippery elm).

Potassium iodide

In one study, the use of potassium iodide had a positive outcome after multiple other pharmaceutical medication failed to resolve EN. Potassium iodide is thought to "stimulates mast cells to release heparin which may lead to suppression of delayed hypersensitivity reactions". Potassium iodide also may decrease free radical formation and neutrophil chemotaxis [1]. Potassium iodide should always be prescribed under the care of medical practitioner.

Supplements should only be used under the guidance of a physician, as some may interact with pharmaceutical medications or not be appropriate in some disease conditions.