General Dermatology

Erythema Nodosum Linked to Better Prognosis in Patients With Sarcoidosis

Estie Mermelstein, MSN, FNP-BC
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Erythema nodosum (EN) is characterized by inflammation of subcutaneous fat cells.3 The condition is 3 to 6 times more common in women and typically occurs between age 25 and 40.14 Pregnancy is the cause of erythema nodosum (EN) in an estimated 2% to 6% of cases.2 Other causes include infection (especially streptococcal), sarcoidosis, and malignancy.14 During pregnancy, EN typically begins in the first trimester or early in the second trimester.2 Erythema nodosum is characterized by spontaneous eruption of firm red, tender, painful nodules on the lower legs (usually the shins) and occasionally on the forearms and thighs.3,14 The nodules typically reach 10 to 40 mm in diameter.12 Accompanying symptoms may include fever, ankle edema, and joint or abdominal pain.14 Most cases of EN resolve spontaneously within 4 to 8 weeks of onset.3,14 Compression stockings, bed rest with leg elevation, and analgesics can help with discomfort.2,3

Erythema nodosum (EN) is characterized by inflammation of subcutaneous fat cells.3 The condition is 3 to 6 times more common in women and typically occurs between age 25 and 40.14 Pregnancy is the cause of erythema nodosum (EN) in an estimated 2% to 6% of cases.2 Other causes include infection (especially streptococcal), sarcoidosis, and malignancy.14 During pregnancy, EN typically begins in the first trimester or early in the second trimester.2 Erythema nodosum is characterized by spontaneous eruption of firm red, tender, painful nodules on the lower legs (usually the shins) and occasionally on the forearms and thighs.3,14 The nodules typically reach 10 to 40 mm in diameter.12 Accompanying symptoms may include fever, ankle edema, and joint or abdominal pain.14 Most cases of EN resolve spontaneously within 4 to 8 weeks of onset.3,14 Compression stockings, bed rest with leg elevation, and analgesics can help with discomfort.2,3

The clinical characteristics and treatment-related features in patients with sarcoidosis are compared based on if EN was a presenting symptom at the time of diagnosis.

Erythema nodosum, the most common non-specific skin manifestation of sarcoidosis, was associated with a good prognosis according to a single-center retrospective cohort study published in Anais Brasileiros de Dermatologia, which adds to the current research supporting this hypothesis.

Investigators analyzed data from patients diagnosed with sarcoidosis from 1994 through 2013 and identified 2 groups of patients: those with erythema nodosum (EN) as a presenting symptom at the time of sarcoidosis diagnosis (EN group) and those without EN as a presenting symptom (non-EN group). They collected demographic data, clinical characteristics, diagnostic methods, and treatment modalities for each patient. They also conducted a systemic evaluation of organ systems for each patient. Constitutional symptoms and organ involvement at presentation were recorded. They also evaluated radiographic staging for pulmonary sarcoidosis, tuberculin tests, ESR and serum ACE levels. An independent-sample t-test was performed to compare the means of normally distributed continuous variables and the Mann-Whitney U test was performed for non-parametric data.

There were 122 patients included in the analysis, 31 in the EN group and 91 in the non-EN group. In both groups, women made up the majority of patients with 83.9% in the EN group and 68.1% in the non-EN group. The age in both groups ranged from 18 to 61 years with a mean age of 44.4 (SD ±12.82) years.

All patients presented with pulmonary sarcoidosis. In the EN group, radiological stages of pulmonary disease were significantly lower than the non-EN group (P =.013) and, therefore, cough was more common in the non-EN group (P =.027).

There were 5 patients in the non-EN group with specific cutaneous lesions of sarcoidosis with histopathological evidence of non-caseating granulomas compared with none of the patients in the EN group.

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In terms of characteristics of systemic involvement, articular manifestations were more common in the EN group (P =.001), while other systemic organ involvement, especially neurological involvement, was significantly more common in the non-EN group (P =.025). There was no statistically significant difference in constitutional symptoms, ESR level or ACE level between the groups.

More patients in the EN group were managed without systemic therapy than those in the non-EN group (71.0% vs 54.9%) and spontaneous remission was more common in the EN group (25.0% vs 14.1%), although these were not statistically significant differences between the groups.

The study was limited by its retrospective design and the varied follow-up times between patients.

Althoughpatients with EN had less systemic organ involvement than non-EN patients, the study authors wrote that they “couldn’t confirm that these patients would need less systemic therapy in the course of their disease.”

Reference

Afacan Yıldırım E, Aladağ Öztürk P, Adışen E, Köktürk N. The relationship between erythema nodosum and prognosis in systemic sarcoidosis: a retrospective cohort study. An Bras Dermatol. Published online July 7, 2022. doi:10.1016/j.abd.2021.09.011

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