Signs of erythema nodosum. Erythema nodosum is a disease that affects the skin and subcutaneous tissues. Complications of erythema nodosum

Erythema nodosum is a disease in which inflammation of the subcutaneous fatty tissue and blood vessels of the skin occurs. It is very common, erythema nodosum occurs especially often during pregnancy.

Symptoms of erythema nodosum

A symptom of erythema nodosum is the appearance of nodules with a diameter of 1 to 3 cm. They often appear on the legs, but can also appear in the thighs, buttocks and arms. As a rule, the appearance of nodules is symmetrical on both limbs. The nodules have a shiny, thin and hot surface, are located just above the surface of the skin and are painful when pressed.

Precursors to the appearance of a rash with erythema nodosum are aching sensations in the joints, a state of general malaise and fever, similar to flu-like conditions.

Causes of erythema nodosum

There are many causes of erythema nodosum and they are quite different. The most common are tuberculosis, streptococcal infections and sarcoidosis. Other main causes of erythema nodosum:

Infectious:

  • Trichophytosis;
  • Inguinal lymphogranulomatosis;
  • Cat scratch disease;
  • Leprosy;
  • Blastomycosis;
  • Histoplasmosis;
  • Coccidioidomycosis;
  • Yersiniosis;
  • Psittacosis.

Non-infectious:

  • Pregnancy;
  • Vaccines;
  • Medicines;
  • Hodgkin's disease;
  • Leukemia;
  • Tumors;
  • Regional enteritis;
  • Ulcerative colitis;
  • Inflammatory bowel diseases;
  • Behçet's syndrome.

Erythema nodosum can occur from the use of salicylates, iodides, bromides, sulfonamides, antibiotics and other drugs, especially from the use of contraceptives and contraceptives. Also susceptible are those people who have varicose veins and thrombophlebitis. These factors explain why pregnant women are highly susceptible to erythema nodosum.

Often, erythema nodosum can be an independent disease. In such cases, it is impossible to determine the cause.

Forms of the disease

The acute form is characterized by an increase in body temperature to 39°C, the appearance of chills, pain in the joints, neck, hips and shoulders. Lumps appear under the skin without clear boundaries. The bright red spots that appear at first disappear within a month.

Subtypes of the chronic form are allergic vasculitis and Beverstedt's vagus erythema. Allergic vasculitis is characterized by a small number of nodules that do not go away and, accordingly, do not change their color. It lasts a very long time, and relapses often occur. With Beverstedt's wandering erythema, nodules appear and fade, and new lesions appear around the perimeter that do not change their color.

Treatment of erythema nodosum

In order to determine the causes and prescribe treatment for erythema nodosum, you need to consult a dermatologist. The doctor will make a diagnosis during a visual examination. During the initial visit, a throat swab is taken to detect streptococcus and stool for Yersinia, and an X-ray of the lungs is taken to rule out sarcoidosis and tuberculosis.

Erythema nodosum rash is usually treated with corticosteroids. But they are not used if there are infectious diseases.

Erythema nodosum is mainly treated with salicylates and a wide range of antihistamines: diazolin, suprastin, Zyrtec, Tavegil, Telfast, Claritin. Sometimes antibiotics are also prescribed. Self-medication or the use of antibiotics on your own is strictly prohibited, as this can cause allergic manifestations and complications in the gastrointestinal tract.

Bed rest is required. Physiotherapy is also used for treatment - warming ichthyol compresses, phonophoresis, UHF, warm compresses on the lower leg, diathermy. After recovery local symptoms immunostrengthening therapy is carried out.

Erythema nodosum during pregnancy

If a pregnant woman develops erythema nodosum, doctors immediately conduct a diagnosis to identify the cause. This is very important, because if the cause is serious illnesses, such as tuberculosis, Behcet's disease or diseases of the gastrointestinal tract, treatment will be much more difficult.

Erythema nodosum has virtually no effect on the baby in the womb. It is more harmful for the mother herself, as it can cause cardiac complications. There are also cases when the disease goes away on its own by the end of the II-III trimester.

In the absence of complications, local treatment is carried out: indovazine is used to lubricate the lesions, chimes and paracetamol are prescribed orally in small quantities. Inflammatory phenomena are relieved with aspirin in small doses, diclofenac is injected.

During treatment of erythema nodosum during pregnancy, it is important to adhere to correct mode rest and sleep. It is also important to determine the load on the vessels in the lower extremities: it should be minimal, but at the same time it should maintain the vessels in good shape. Depending on the severity of the disease, the doctor will prescribe either alternating physical activity with rest, or bed rest. It is very important to choose the right treatment, otherwise, even after childbirth, erythema nodosum may not go away, but take a chronic form, in which it will constantly worsen in spring and autumn, as well as during unfavorable conditions (stress, climate change, infectious diseases) or the next pregnancy.

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There are various dermatological diseases, some of which are classified as allergic vasculitis. This is inflammation of various vessels - arteries, veins, capillaries, venules. Erythema nodosum belongs specifically to this group of ailments. What it is and how it is treated, we will consider further.

Erythema nodosum or erythema nodosum - what is it?

Erythema nodosum is a disease that is manifested by inflammation of small vessels of the skin and subcutaneous fat. Painful nodules of varying sizes from 5 mm to 5 cm form on the skin. To the touch, these are spherical dense nodules that mainly affect the lower extremities.

A characteristic feature of the disease is the symmetrical location of the affected areas.


The disease most often affects young people 20–30 years old, while the female half of the population suffers from erythema more often than the male half. It also does not bypass children, who endure it more severely than adults.

The disease can manifest itself as an independent disease and is then called “primary”, but most often it is a concomitant symptom of some pathology and in this case it is called “secondary”.

Causes

Doctors still cannot explain exactly why primary erythema nodosum develops in humans. And the majority is inclined to believe that heredity - genetic predisposition - is to blame for everything.

People with the following ailments are prone to a chronic course of the disease:

  • vascular diseases ( varicose veins veins, and atherosclerosis lower limbs);
  • allergic diseases ( bronchial asthma, dermatitis, hay fever);
  • chronic infectious diseases (tonsillitis, sinusitis and pyelonephritis).
Secondary erythema has various causes; its development can be triggered by the following factors:

Non-infectious

  • inflammatory processes in the intestines - enteritis or ulcerative colitis;
  • vaccination;
  • pregnancy;
  • taking some pharmacological agents, such as antibiotics, salicylates, bromides and iodides, sulfonamides, oral hormonal contraceptives;
  • leukemia - blood cancer;
  • various neoplasms of a benign and malignant nature;
  • sarcoidosis is a disease that affects many internal organs, in particular, the lungs. Nodules - granulomas - form in the affected tissues;
  • lymphogranulomatosis or Hodgkin's disease - cancer lymphatic system;
  • Behcet's disease is a chronic disease that mainly affects residents of the Mediterranean, Japan and the Middle East. The patient suffers from ulcerative, ulcerative lesions of the genital organs and inflammation choroid eyes.

Infectious

  • streptococcal - sore throat, acute pharyngitis, erysipelas, scarlet fever, cystitis, otitis, streptoderma;
  • tuberculosis;
  • sexually transmitted diseases - syphilis, gonorrhea, ;
  • diseases of fungal origin - histoplasmosis, coccidioidomycosis, blastomycosis, trichophytosis or ringworm;
  • yersiniosis - caused by pathogenic microorganisms;
  • hepatitis B;
  • cytomegaloviruses and Epstein-Barr virus- these are viruses of different herpes types;
  • psittacosis or “parrot disease” - acute infection, transmitted from feathered pets (parrots, canaries and finches) to humans;
  • felinosis or “cat scratch disease.”

Classification of the disease and its symptoms

The main symptom of the disease is the formation of compactions in the subcutaneous tissue. They range in size from 0.5 mm to 5 cm. Skin covering above them reddens and rises above healthy areas, which, in turn, swell. There is no itching. Nodules are characterized by rapid growth to a certain size. Pain is felt not only when pressing, but also with any load on the legs - when walking or lifting weights. Ripening occurs after 2–3 weeks, color changes.



There are three types of disease:
  • Spicy. This form most often affects children, adolescents and young women. Edema forms on the feet and legs, sometimes on the thighs and rarely on the forearms. They are vague and located symmetrically on both legs. When pressed, pain occurs. The skin over the nodes is first red, and then becomes purple, then yellow-green. Nodes do not develop into ulcers. In the acute form, they disappear within 3–6 weeks and do not leave any scars or scars on the skin. And also there is no relapse of the disease.

    The disease is accompanied high temperature up to 39 °C, general weakness, joint and muscle pain, an excess of white blood cells in the blood - leukocytes, as well as increased speed erythrocyte sedimentation rate (ESR).

  • Migratory. The disease lasts several months. First, one knot appears on the lower leg. The skin over it is red-bluish, the compaction itself eventually transforms into a ring-shaped plaque, the center of which is pale and sunken. Sometimes several more small nodules appear on the legs. This form is characterized by low-grade fever, which stays around 37.5 °C for a long time, the patient is getting worse general state health, he gets chills and suffers from pain in his joints.
  • Chronic. It most often affects mature and elderly representatives of the fairer sex, who have a history of chronic diseases, inflammatory processes or neoplasms. The nodes are weakly expressed and cannot be seen visually, since the color of the skin does not change. They are detected by palpation. They are usually located on the legs and do not go away - when some nodes resolve, others form again. IN spring-autumn period an exacerbation of the disease is observed.


Differential diagnosis of erythema nodosum


Differential diagnosis is a diagnosis that, based on facts or symptoms, excludes diseases and, in the end, leads to the formulation of a single correct diagnosis.

Erythema nodosum can be confused with the following diseases:

  • Thrombophlebitis. In this case, the disease also forms compactions that are painful when pressed, but they are localized along the veins and have a tortuous appearance. The patient complains of muscle pain, legs swell. If the blood clot becomes infected, then intoxication of the body occurs - the patient suffers from weakness and high fever.
  • Erysipelas or erysipelas- an acute infectious disease caused by streptococcus. There is a sharp rise in temperature to 38–39 °C and weakness. Then burning and pain in the affected areas, which swell over time. The area of ​​redness has jagged edges, rises above healthy skin, and feels hot and tight to the touch. Sometimes bubbles form that are filled with liquid. Unlike erythema nodosum, erysipelas is characterized by inflammation lymphatic vessels and nodes.
  • Erythema of Bazin or indurative tuberculosis. Rashes form on the back of the lower leg. Nodes form slowly. They do not become inflamed and do not rise above healthy areas. The skin over them has a blue-red color, which does not tend to change. However, the nodes can turn into ulcers and leave behind scars.
  • Christian-Weber disease. Characterized by inflammatory processes in subcutaneous fatty tissue. Small subcutaneous lumps form on the forearms, thighs and torso, which are moderately painful when pressed.

Erythema nodosum in pregnant women

If earlier the appearance of this disease in a pregnant woman was perceived negatively by specialists and they insisted on terminating the pregnancy, since it was believed that it threatened the development of congenital defects in the fetus, now it has been proven that erythema is more dangerous to a woman’s health - it affects the state of the cardiovascular system, but the child, basically, does not affect.

Therefore, when primary form doctors advocate saving the child, sometimes the disease goes away by the end of the second or third trimester. The main thing is to find the cause of the secondary disease in a pregnant woman; only after an accurate diagnosis is made, treatment is prescribed.



Pregnant women with vascular problems lower extremities suffering from thrombophlebitis or varicose veins are more susceptible to this disease.


During treatment, a specialist may prescribe bed rest or alternating physical activity and a period of rest. Reduce the load on the legs, but make sure that the muscles of the lower extremities are in good shape or, otherwise, their atrophy may occur.

In severe cases, the disease may not go away even after pregnancy. Quite often it becomes sluggish or worsens in the spring-autumn period.

Erythema nodosum in children

The causes of this disease in children have not been fully identified. In most cases, it is caused by viral infections:
  • In newborns and infants, this may be a reaction to tuberculosis intoxication.
  • At a relatively older age, staphylococci, streptococci and candida become the culprits. The risk of developing the disease increases with the predominance of pathogenic microflora in the intestines.
  • In some cases, this is the body’s reaction to medications - iodine, antibiotics and others.
An upset stomach is added to the symptoms of infantile erythema.

As a separate disease, erythema nodosum was isolated and defined in 1807 at the suggestion of the English dermatologist Robert Willan. Subsequent study showed that it is a form of vasculitis allergic etiology. Today, pathology is more often diagnosed in young people from twenty to thirty years old. Until the age when it starts puberty, the disease equally often affects both boys and girls, but after that it is mainly women who suffer from erythema nodosum.

Allergic vasculitis develops as a complication after undergoing bacterial infections(angina, otitis, scarlet fever and pharyngitis). Long-term progression may contribute to the appearance of erythema nodosum. systemic disease(tuberculosis, trichophytosis, yersiniosis and lymphogranulomatosis). In addition, the formation of a nodular rash on the legs can be caused by long-term use of antibiotics, sulfonamides and bromides. Cases have been described in which characteristic symptoms appeared in children after vaccination.

There are provoking factors that are not associated with bacterial or viral infection. Often, damage to the lower extremities is observed in ulcerative colitis, oncology, and Behçet's disease. Hormonal changes that occur in a woman’s body during pregnancy also often become a trigger. If expectant mother If you have a history of chronic foci of infection, the risk of developing pathology increases significantly.

Scientists tend to assume that there is a hereditary predisposition to this disease. This version is supported by the facts that erythema nodosum is diagnosed in close relatives in several generations. Chronic forms develop in those who have a history of allergy status.

Symptoms and signs of erythema nodosum

The described disease has a characteristic clinical picture.

  1. The pathology begins acutely. The patient complains of deterioration general well-being, the appearance of signs of fever, chills. He is tormented by weakness and loses his appetite.
  2. Then rashes appear on the skin. Rash elements are nodes that form in the dense layers of the dermis or in the subcutaneous tissue. They rise above the upper layer of the epidermis, the skin around them swells, so it is difficult to determine the boundaries of each element. The nodes can have different sizes, the diameter can vary from 5 mm to 5 cm. The skin over them is smooth, its color is red. Education tends to rapid growth, but upon reaching a certain size, the growth process stops. The nodes are compacted. The color of the skin above them becomes purple-blue.
  3. The formation of a rash is accompanied by pain. It may be different for different people. In some it occurs spontaneously, in others it appears only upon palpation of individual elements.
  4. There is no itching.
  5. Most patients experience the development of arthropathy. It manifests itself in the form of joint pain and a feeling of stiffness of mobility. In a third of patients, large joints located closest to the areas of future skin lesions become inflamed. They swell, and the skin over them becomes swollen and hot to the touch.

The acute period lasts a month, then in the absence proper treatment goes into chronic stage. It is characterized by alternating periods of exacerbations and remissions. Repeated relapses are characterized by the appearance of single elements of the rash. They form and do not go away for several months. Symptoms of intoxication are mild or completely absent.

IN separate group doctors identify erythema migrans. It occurs subacutely: without pronounced clinical manifestations. The patient feels slightly unwell, his joints hurt, the pain is moderate. Body temperature does not rise above 37 degrees. Against this background, a single node forms on the front side of the shin. It has a dense structure and clear boundaries. The skin over it is bluish-red. Over time, the infiltrate migrates, and a ring-shaped plaque appears in its place. It has bright red edges and a pale center. Later, if the disease progresses, other small nodes appear on both legs. But exactly two months later they disappear as quickly as they appeared.

Classification

There are other types of the disease, the symptoms of which are somewhat different from the clinical picture of the typical form of erythema nodosum. They have different causes, so doctors use the following classification to create an effective form of treatment.

Name Manifestations
Toxic More often diagnosed in newborns, it is considered a physiological form. The rash appears suddenly, lasts for a week, and then disappears on its own. No other symptoms are observed
Infectious Occurs as a complication after acute infections
Multiform (exudative) Develops after previous colds, the appearance of a nodular rash is preceded by general deterioration well-being. The patient experiences severe headache, sore throat and joint pain. Rashes may appear on the legs (shins), palms, oral mucosa, hands and feet, and genitals. The formation of nodules occurs in several stages: first red spots, then compactions with clear boundaries. They degenerate into vesicles containing serous contents. When they open, bleeding erosion is exposed in their place. Possible death if left untreated

Erythema nodosum (nodosum) in adults and children is diagnosed based on an initial examination by a dermatologist. He carefully collects anamnesis, compares its data and finds out why the disease develops (as a complication of systemic pathologies or as a preceding symptom).

Then the patient must be prescribed full examination. It should help clarify the etiology of the pathology. For these purposes the following is carried out:

  • clinical blood tests;
  • fluoroscopy;
  • tomography chest;
  • throat swab analysis;
  • skin tests for allergies;
  • biopsy of nodes.

Such studies make it possible to differentiate erythema nodosum from migratory thrombophlebitis, panniculitis, gummous syphilis, skin tuberculosis, and malignant neoplasms.

Drug therapy

Modern diagnostics make it possible to accurately determine the cause of the development of erythema nodosum, so it is possible to develop effective therapeutic regimens. Patients are prescribed bed rest and advised to keep their legs elevated. Reverse flow of blood helps reduce the temperature inflammatory reaction and pain intensity.

Choice medicines largely depends on the results of the analyzes performed. The main emphasis is on eliminating the causes of the disease, while existing symptoms are also relieved. For this we use:

  1. Nonsteroidal anti-inflammatory drugs (Ortofen, Ibuprofen, Diclofenac). Effective for mild forms of pathology.
  2. Aminoquinoline drugs (Plaquenil, Delagil). They relieve inflammation and pain well, and promote the removal of toxins.
  3. Iodine-containing solutions (potassium iodide solution). Reduce thrombus formation and stimulate local blood circulation.
  4. Antihistamines (Loratidine, Fexofenadine). Relieves expression allergic reaction, help reduce swelling of the affected areas of the skin.
  5. Antibiotics. Prescribed if erythema nodosum develops against the background of bacterial infection. During pregnancy, they are used extremely carefully, taking into account the gestational age of the fetus.
  6. Angioprotectors (Curantil, Pentoxifylline). Strengthen the tone of the walls of blood vessels, reduce swelling of the skin, and improve the rheological properties of blood.
  7. Hormonal drugs (Prednisolone, Diprospan). Their use becomes justified only in the presence of a pronounced inflammatory process, in the event that the ongoing drug treatment turns out to be ineffective.

If the course is persistent and protracted, plasmapheresis and hemosorption are required.

Local therapy

Applications with Ichthyol solutions are used to treat affected areas of the skin. Dimexin gels in combination with Heparin are also actively used. To treat areas with extensive lesions, Beloderm, Belosalik or Belogent are selected.

Physiotherapy

After cupping acute symptoms Physiotherapy procedures are prescribed for the inflammatory process. The following help significantly alleviate the patient’s condition:

  • laser treatment;
  • exposure to ultra-high frequency currents;
  • magnetic therapy;
  • inductothermy.

Their use stimulates regeneration processes and brings recovery closer.

Traditional medicine recipes

Treat erythema nodosum folk remedies in the acute phase is undesirable. The use of herbal decoctions and infusions, compresses and applications can cause an allergic reaction, which will significantly complicate the course of the disease. Experts advise using some recipes during periods of remission. In this way, you can extend their duration and prevent the occurrence of another attack of exacerbation.

It is useful to select plants that have immunomodulatory properties for the preparation of medicinal potions. These include wild rosemary, aralia roots, wheatgrass, rose hips, and plantain leaves.

For prevention inflammatory processes A collection that includes meadowsweet flowers, black elderberry, calamus roots, burdock and birch leaves, and goat willow bark is perfect.

The recipes for preparing the products are extremely simple. You need to take any two plants from each group, mix 50 grams of each in a mortar, and then pour 500 ml of water into a tablespoon of the mixture. Everything is boiled over low heat for five minutes, then the composition is poured into a thermos and kept for an hour and a half. After the expiration date, 50 drops of calendula tincture or pharmaceutical citrosept are added to the finished decoction. Everything is thoroughly mixed. The finished medicine is drunk warm three times a day an hour before meals. The duration of the course is one and a half months. Then you can prepare a collection from another pair of unused herbs.

For local treatment it is better to prepare an ointment from fresh leaves birch, plantain and raspberry. The raw materials are pre-ground using a meat grinder or blender, then castor oil or melted pork fat is added to it in proportions of 1:4. The mixture is preheated in a water bath for about an hour, cooled, and then rubbed into the affected areas of the skin twice a day (morning and evening).

You can relieve swelling with compresses made from leaves of lingonberry, knotweed, bearberry, chestnut, lemon balm, sweet clover, rue or hawthorn flowers.

It is a good idea to do an allergy test before using any recipe.

Prevention methods

There is no list of clear recommendations that, if followed, would help prevent the development of erythema nodosum. Therefore, experts recommend promptly treating diseases that can provoke its occurrence and constantly strengthening the immune system.

Erythema nodosum is a lesion of the subcutaneous and cutaneous vessels, of allergic origin and inflammatory nature, manifested by the formation of compacted painful inflammatory nodes in the shape of a hemisphere of various sizes. Most often, erythema nodosum is found on symmetrical areas of the legs. Diagnosis of the disease is carried out through an examination by a dermatologist, laboratory tests, X-ray examination of the lungs, the conclusion of a rheumatologist, pulmonologist and other specialists. Treatment of erythema nodosum consists of eliminating foci of infection, taking antibiotics, anti-inflammatory general and local treatment, using ILBI and physiotherapy, and extracorporeal hemocorrection.

What is erythema nodosum

The name “erythema nodosum” was introduced by the British dermatologist Robert Willan in 1807. For a long time, the disease was classified as a specific nosological entity. After some time, dermatologists conducted studies that proved that erythema nodosum is one of the variants of allergic vasculitis. Erythema nodosum differs from systemic vasculitis by its characteristic local vascular involvement, which is mainly limited to the lower extremities.

People of all types can get erythema nodosum. age categories, but more often it occurs in 20-30 year old patients. Both boys and girls can get erythema nodosum before puberty, and after puberty the likelihood of the disease in men becomes several times less than in women. Cases of erythema nodosum become more frequent in the spring and winter.

Causes of erythema nodosum

The main reason for increased sensitivity of the body with the progression of erythema nodosum is infectious processes. Primarily caused by streptococcus (scarlet fever, tonsillitis, streptoderma, erysipelas, acute pharyngitis, cystitis, otitis, rheumatoid arthritis and other diseases), tuberculosis, less often - coccidioidomycosis, yersiniosis, inguinal lymphogranulomatosis, trichophytosis. Erythema nodosum also occurs due to the body's sensitivity to medications. Sulfonamides, salicylates, bromides, iodides, vaccines and antibiotics are the most dangerous drugs in this regard.

This disease often accompanies sarcoidosis. Erythema nodosum can also develop due to non-infectious diseases such as Behcet's disease and Crohn's disease, paraproctitis, ulcerative colitis or cancer pathologies.

Patients who have vascular disorders(atherosclerosis, varicose veins), allergic diseases (hereditary allergic dermatosis, bronchial asthma, hay fever), chronic infections (sinusitis, pyelonephritis, tonsillitis) are more predisposed to this disease.

Symptoms of erythema nodosum

Dense nodes located in the lower parts of the skin or subcutaneous tissue may be typical symptoms erythema nodosum. Their diameter varies from 5 mm to 5 cm. The skin over the nodes is smooth and red. The boundaries of erythema nodosum are blurred due to the fact that the surrounding tissues swell, and the erythema itself rises slightly above the skin. The nodes stop enlarging when they reach a certain size. Pain syndromes in patients are expressed differently and can be observed not only during palpation of nodes, but also spontaneously. After a few days, the nodes become denser. The skin is red, gradually becoming brown, then bluish, greenish and yellow. This discoloration may resemble a bruise.

The most typical location of the nodes is the anterior surface of the legs. Symmetrical lesions are also found, but single or unilateral lesions are possible. Erythema nodosum can occur on the calves, buttocks, thighs, forearms, face (in the subcutaneous fat), or even in connective tissue eyeball(episclera).

Most often, erythema nodosum will be characterized by acute onset, increased body temperature, chills, painful condition, or even anorexia. More than half of the patients may experience secondary joint damage (arthropathy): arthralgia (joint pain), discomfort on palpation, feeling of stiffness in the morning. In less than half of patients, along with subjective symptoms of erythema nodosum, objective signs arthritis: swelling and reddened skin in the area of ​​the affected joint, increased local temperature, concentration of fluid inside the joint (effusion). With erythema nodosum, the articular syndrome differs in that large joints will be affected symmetrically, and small joints may leak. Symptoms and secondary joint lesions (arthropathy) may appear before the skin elements of erythema nodosum.

Typically, complete resolution of erythema nodosum occurs within a few weeks. Temporary darkening (hyperpigmentation) and peeling of the skin can be observed at this site. Along with the skin signs of the disease, the joint syndrome also disappears. So the acute form of erythema nodosum can last about a month in total.

Such consequences of erythema nodosum as chronic and recurrent course of the disease are observed much less frequently. An exacerbation of the disease is characterized by the appearance of a small number of dense bluish-pink nodes, which can persist for up to several months. Skin symptoms may be accompanied by chronic secondary lesions of the joints without their deformation.

Diagnosis of erythema nodosum

With erythema nodosum, changes in laboratory results are general. However, they make it possible to distinguish the disease from other abnormalities, to identify its etiology and concomitant pathology. In chronic relapse or acute form of erythema nodosum, a complete blood count reveals excessively rapid erythrocyte sedimentation (ESR) and neutrophilic leukocytosis. The presence of streptococcal infection is often detected by culture from the nasopharynx. If there is a suspicion of yersiniosis (an infectious disease that affects the stomach and intestines, which tends to infect various systems and organs), bacteriological culture of stool is performed; To exclude tuberculosis disease - tuberculin diagnostics. An indication for consultation with a rheumatologist and a blood test for rheumatoid factor will be severe articular syndrome.

In severe cases, a dermatologist, in order to confirm the diagnosis of erythema nodosum, prescribes special study(biopsy) for one of the nodes. Histologically studied material helps to identify the presence of an acute inflammatory process in the walls of small veins and arteries, in the interlobular septa at the border subcutaneous tissue and skin. It is possible that consultation with various specialists in the field of pulmonology, infectology, otolaryngology, vascular surgery and phlebology to determine the causes of erythema nodosum, concomitant sources of chronic infection or vascular disorders.

For the same purpose, to diagnose erythema nodosum, specialists can prescribe pharyngoscopy and rhinoscopy, computed tomography and radiography of the lungs, ultrasound Dopplerography of veins and rheovasography (RVG - diagnosis of the lower extremities). X-ray is aimed at examining the chest and identifying concomitant diseases, such as tuberculosis, sarcoidosis or other processes in the lungs. A frequent, but not necessarily encountered, radiological companion of the disease is an increase lymph nodes(unilateral or bilateral) lung root.

Differential diagnosis of erythema nodosum is carried out with erythema induratum if a person has skin tuberculosis, migratory thrombophlebitis, polyarteritis nodosa, panniculitis, or has syphilis gummas.

Treatment of erythema nodosum

The effectiveness of treatment of erythema nodosum strongly depends on the results of treatment of the causative or concomitant illness. Treatment and preventive measures are taken for chronic foci of infection, systemic use antibiotics, desensitizing therapy. To suppress inflammatory processes and relieve pain for erythema nodosum, doctors prescribe non-steroidal anti-inflammatory drugs: diclofenac sodium, nurofen, ibuprofen, etc. The use of plasma-, cryoapheresis, hemosorption (extracorporeal hemocorrection) and ILBI (intravenous laser irradiation blood) helps to quickly relieve the symptoms of erythema nodosum.

For local treatment, specialists prescribe anti-inflammatory ointments, and special bandages with dimexide preparations are applied to the area of ​​sore joints. For erythema nodosum, physiotherapeutic methods of treatment have an effect ultraviolet irradiation in erythemal doses (UVR), laser and magnetic therapy, phonophoresis with hydrocortisone (an anti-inflammatory drug) on ​​the area of ​​​​inflamed nodes or affected joints.

Dermatosis erythema nodosum, or erythema nodosum, is a disease characterized by damage to the skin vessels by an inflammatory process (vasculitis, angiitis) with the appearance of painful formations in the form of nodes in the subcutaneous fatty tissue and dermis.

The latter are usually localized along the anterior and anterolateral surfaces of the thighs and legs.

Causes of erythema nodosum

Prevalence

Erythema nodosum occurs in 5-45% of the population, especially common in at a young age. As a result of epidemiological studies, it has been established that in different regions the incidence rate differs significantly and largely depends on the predominance of a particular pathology characteristic of a particular area. However, complete statistics on the prevalence of this disease are insufficient. It is only known that in the UK, 2-4 cases are registered per 1000 population every year.

The name of the disease was proposed at the end of the 18th century, and its clinical symptoms were described in detail in the second half of the 19th century. In subsequent years, some features of the clinical manifestations of erythema nodosum in many infectious processes with chronic course, proposed various schemes treatment, but the specific etiological factor has not yet been established, and the frequency chronic forms remains quite high.

Differences in incidence between urban and rural populations and between genders adolescence not noted. However, after puberty, girls and women are affected 3-6 times more often than boys and men.

It is generally accepted that pathology develops mainly against the background of other diseases, of which sarcoidosis is the most common. Although people of any age are at risk of developing erythema nodosum, young people 20-30 years of age are more often affected. This is due to the fact that the maximum incidence of sarcoidosis occurs precisely in this age period. Often, after an X-ray examination of the chest organs in patients who come with clinical picture erythema nodosum, sarcoidosis was detected.

A higher incidence of erythema nodosum is observed in winter and spring. This may be due to the seasonal increase in the number of colds caused by beta-hemolytic streptococcus group A. Isolated cases of familial lesions of erythema nodosum, especially children, have also been described, which is explained by the presence among family members of a constant source of the infectious pathogen (beta-hemolytic streptococcus group A) .

Etiology

The connection with streptococcus and sensitization of the body to its antigen (streptolysin) are confirmed increased content antibodies in the blood of patients representing antistreptolysin-O (ASLO).

There are many diseases that cause erythema nodosum. In addition to sarcoidosis, these include tuberculosis, especially in childhood, chorea, acute and chronic infections (angina, pleuropneumonia, chronic tonsillitis, chlamydia, yersiniosis, measles), syphilis, various autoimmune diseases (systemic lupus erythematosus, rheumatoid arthritis, dermatomyositis, etc.).

However, the development of erythema nodosum against the background of these pathological conditions does not yet indicate that they are its cause, which is fully consistent with the Latin proverb:

“Posthocnonestpropterhoc” - after “this” does not mean because of “this”.

Many of the listed diseases are provoked by staphylococci, streptococci, viruses, including some types herpetic virus, as well as long-term use (for example, with an autoimmune disease) of glucocorticoid drugs that promote the activation of infection. This fact has led to the assumption that infectious pathogens, especially streptococci and staphylococci, are the cause of erythema nodosum.

At the same time, the development of the process is often observed in diseases or conditions not associated with bacterial flora - hepatitis “B” and “C”, chronic active hepatitis, HIV infection, ulcerative colitis, inflammatory bowel diseases (colitis), disease Crown, arterial hypertension, peptic ulcer, chronic cardiovascular failure, pregnancy, antiphospholipid syndrome, blood diseases, smoke inhalation by firefighters, jellyfish burns and others.

In addition, erythema nodosum can develop immediately after taking a number of medications. One scientific paper lists about 80 such drugs. various groups and classes - oral contraceptives, bromides, codeine, antidepressants, antibiotics, sulfonamides, nonspecific anti-inflammatory, antifungal, antiarrhythmic, cytostatic drugs, etc.

Depending on the etiological factor the disease is defined as:

  1. Primary, or idiopathic if primary pathological condition or causative factor not identified. The number of such cases ranges from 37 to 60%.
  2. Secondary - when establishing an underlying disease or factor that can be considered the cause.

Predisposing factors include hypothermia, seasonality, the presence of chronic diseases, malignant or benign neoplasms, venous and/or lymphatic insufficiency of the vessels of the lower extremities, medications, metabolic disorders and many others.

Pathogenesis and pathomorphological picture

The body's immune response

With regard to the mechanisms of disease development, most authors give primary importance to the hypothesis of an immediate or delayed immune reaction of the body in response to exposure to bacterial, viral or other provoking antigens. Quite often the development of the disease after taking certain medicines and the identity of the skin elements in erythema nodosum to rashes in allergic diseases confirms the assumption of the allergic nature of this pathology.

The skin is an area that quickly responds to the influence of a provoking agent. Under its influence, immune complexes are produced, which, circulating in the blood, settle and accumulate on the walls and around the walls of small vessels (venules) located in the connective tissue partitions of the subcutaneous tissue.

These immune complexes activate B lymphocytes, which secrete antibodies. As a result, a hyperergic (excessive) reaction of local tissues occurs, which is characterized by inflammation, activation of vascular-active and thrombus-forming substances and necrosis. This reaction is accompanied by redness, sometimes itching, and the formation of an infiltrate (swelling, thickening). It is similar to the Arthus phenomenon - an allergic reaction immediate type. A delayed-type allergic reaction cannot be ruled out, in which T-cells are activated, and the disease follows the same type as contact dermatitis.

Hereditary predisposition

The hypothesis of hereditary predisposition is not rejected either. It's connected with high frequency detecting elevated levels of TNF-alpha (tumor necrosis factor), high concentration in the blood of IL-6 (interleukin), which is not associated with the presence of an infectious disease, and a high frequency of the presence of HLA-B8 (human leukocyte antigen) in the blood of women with erythema nodosum.

It is assumed that when the process enters the chronic stage, some infectious pathogens are included in the mechanisms of development of vasculitis and damage to the endothelial (inner) lining of blood vessels, which impart more pronounced aggressiveness to this process.

Pathomorphology

Pathological studies of materials obtained through skin biopsy indicate that the results depend on the stage pathological process. This reveals signs of damage characteristic of an excessive delayed-type allergic reaction. The inflammatory process in the walls of venules and arterioles is combined with their dilation (expansion), which causes the erythematous (reddish) color of the elements in the initial stages of the disease.

The interlobular connective tissue septa of adipose tissue, located at the border of the dermal layer and hypodermis, are thickened and have signs of fibrosis. They're in varying degrees permeated with cells extending to the peri-septal zones. These cells, among which lymphocytes predominate, are involved in inflammatory processes. The skin inflammatory process and fibrosis of the septa explain the presence of characteristic dense nodules (granulomas).

In the acute course of erythema nodosum, the main morphological changes are localized mainly in the subcutaneous fatty tissue, and in the dermal layer only nonspecific swelling around the vessels is detected. In subacute cases, along with inflammation of the walls of small subcutaneous vessels, infiltration of the interlobular septa is determined, in chronic (the most common form) - subcutaneous vasculitis (inflammation) of not only small but also medium vessels, as well as thickening of the wall and proliferation of cells in the inner lining of the capillaries of the interlobular septa.

Erythema nodosum and pregnancy

This disease during pregnancy, according to various sources, is diagnosed in 2-15% of women. It is believed that the same mechanisms underlie its development. Pregnancy is a unique state of a woman's body. It is possible only if there is a balance between nonspecific and specific types immunity. It is these factors that direct the immune response along a certain “channel”.

Restructuring of endocrine and immune systems during the gestation period it is a vulnerable link, which creates conditions for the occurrence of erythema nodosum. Acute or activation chronic infection during gestation, against the background of physiological immunosuppression (suppression of immunity), it turns on the mechanisms of the latter to an even greater extent, which contributes to the sensitization of the vascular network of the dermis and hypodermis and leads to the threat of miscarriage.

How, in what period and with what to treat erythema nodosum during pregnancy are always difficult questions for doctors that must take into account Negative influence not only the disease itself, but also medications for the fetus. Antibiotics and antibacterial drugs during the formation of organs and systems of the unborn child (in the first trimester of pregnancy).

Thus, the main role in the etiology and pathogenesis of the disease is given to the body’s immune response to the influence of an infectious or non-infectious damaging agent. The role of the human body’s reactivity in this process, as well as all the links in the mechanisms of its interaction with aggressive agents, remain sufficiently unexplored.

The predominant localization of the pathological process on the legs is also not entirely clear, which is mainly associated with slow blood and lymph flow and structural features muscle tissue and the vascular network of the lower extremities and with congestion in them.

Symptoms of erythema nodosum

Depending on the severity, nature of the course and duration of the inflammatory process, the following forms of the disease are distinguished:

  1. Spicy.
  2. Migrating.
  3. Chronic.

Acute erythema nodosum

It is a classic type, but not the most common variant of the course, the development of which is usually preceded by an acute infectious disease (tonsillitis, ARVI, etc.).

It is characterized by the sudden appearance on the legs in the area of ​​the anterior and lateral surfaces of the legs (sometimes the thighs) of typical multiple elements in the form of subcutaneous nodes with a diameter of 5 to 60 mm or more, which can merge with each other, forming red plaques, and are never accompanied by itching . The occurrence of rashes is accompanied by pain different intensity, both at rest and when palpating them.

The nodes have a dense consistency and unclear outline (due to tissue swelling), and slightly rise above the surrounding healthy skin surface. They quickly grow to a certain size, after which their growth stops. The skin located above them is smooth and red. Regression of granulomas can occur on their own within 3 (in mild cases) or 6 (in more severe cases) weeks.

Their reverse development is never accompanied by the formation of ulcers and or. The nodes disappear without a trace, but sometimes peeling of the epidermis and/or hyperpigmentation may temporarily remain in their place.

Erythematous lesions are usually located symmetrically, but occasionally on one side, or are represented by single nodes. Very rarely, granulomas appear on the arms, neck and face, where they can merge with each other, forming erythematous (red) plaques, and sometimes extensive, merging lesions.

Localization of the process on the palmar and plantar (plantar) surfaces is usually one-sided and is more common in children, very rarely in adults. Plantar localization of erythema nodosum must be distinguished from the so-called plantar traumatic urticaria, which looks like areas of reddened skin on the soles. The latter occurs in children as a result of significant physical activity. Dynamic observation makes it easy to distinguish erythema nodosum from plantar erythema, in which the redness disappears within a few hours to 1 day.

Quite often, the onset of the acute form of erythema nodosum is accompanied by high body temperature (up to 39°) and general subjective symptoms - weakness, malaise, headache, abdominal pain, nausea, vomiting and diarrhea, pain in the joints and muscles. Approximately 32% of patients have symptoms of an inflammatory process in the joints - intra-articular effusion, the presence of skin hyperemia and tissue swelling in the joint area.

1. Plantar localization; 2. Localization of erythematous nodes on the legs

Migratory form

Proceeds with similar ones described above, clinical manifestations, but, as a rule, it is asymmetrical in nature and has a less pronounced inflammatory component. The disease begins with the appearance in a typical area (anterolateral surface of the leg) of one flat node of pasty consistency and cyanotic (bluish) color.

The node quickly grows due to its peripheral zones and transforms into a deep, large plaque with a sunken and pale central part. Peripheral departments it is surrounded by a richly colored ridge. The main node can be accompanied by single small nodes. The latter are often located on both legs. General symptoms are also possible - low fever, joint pain, general weakness and malaise. The duration of the migratory form ranges from several weeks to months.

Chronic form

Usually develops in women in middle and old age, more often against the background of cardiovascular disease (chronic heart failure, obliterating atherosclerosis and varicose veins lower extremities), allergic, infectious-inflammatory (adnexitis, etc.) or tumor pathology, for example, uterine fibroids.

This form of erythema nodosum is characterized by a long, persistent course. It occurs with relapses that occur in the spring and autumn periods and last for several months, during which the reverse development of some nodes occurs and the emergence of new ones.

There are usually several nodes, they are dense, have a diameter of about 40 mm, bluish-pink in color, are localized on the anterolateral surface of the leg, are accompanied by mild pain and moderate intermittent swelling of the leg and/or foot. At the initial stage of their appearance, the color of the skin may not change, and the granulomas themselves can only be determined by palpation. General symptoms may be mild or absent altogether.

Diagnostics

The main role in making a diagnosis is played by external inspection and careful collection of anamnesis (medical history) data. Anamnesis allows us to identify concomitant and/or previous diseases against which erythema nodosum developed and which may be its main cause.

A mandatory examination is radiography or, more reliably, CT scan chest organs. Availability in research results double-sided zoom intrathoracic lymph nodes in combination with erythema nodosum and elevated temperature body and in the absence of symptoms of pulmonary tuberculosis usually indicates Löfgren's syndrome. It often occurs in women during pregnancy and the postpartum period. Löfgren's syndrome is one of the mild forms of pulmonary sarcoidosis that requires appropriate therapy.

What tests need to be taken?

General blood tests are not very informative. They can only indicate (not always) the presence of an inflammatory (accelerated ESR) and/or allergic (increased number of eosinophils) process.

To some extent, tests to determine the titers of antistreptolysin-O in two samples with an interval of 2-4 weeks are useful. A change in titer of at least 30% indicates an inflammatory streptococcal infection in the recent past.

In particularly difficult cases, as well as in case of resistance to treatment and persistent course of the disease, in order to carry out differential diagnosis A biopsy of the affected area is performed, followed by histological examination (the histological picture is described above).

Treatment of erythema nodosum

If there is a pronounced picture of the disease, it is necessary to adhere to bed rest for a week, which helps reduce swelling of the lower extremities and the intensity of pain. In this case, it is recommended to give the legs an elevated position, and in case of severe symptoms, use elastic stockings or bandaging with elastic bandages.

Drug therapy

  1. For moderate and mild forms of erythema nodosum, treatment begins with the use of one of the drugs from the class of NSAIDs (nonsteroidal anti-inflammatory drugs) - Ibuprofen, Paracetamol, Indomethacin, Ortofen, Diclofenac, Naproxen, Ibuklin, Meloxicam, Lornoxicam, Nimesulide, etc. They are taken for 3-4 weeks.
  2. Antibiotics, antibacterial and virusostatic agents. If possible, it is advisable not to prescribe them to pregnant women in the first trimester. The safest antibiotics for the fetus are penicillin group antibiotics (Ampicillin and Oxacillin), cephalosporins (Cefalizin, Ceftriaxone, Cefoxitim) and macrolides (Azithromycin, Erythromycin). But it is better to use them and other antibacterial agents in the second trimester, and in the second half of pregnancy the range of antibiotics used can be expanded.
  3. Aminoquinoline drugs Delagil or Plaquenil, which have anti-inflammatory, antiplatelet, antimicrobial, analgesic, antioxidant and other effects. Their administration to pregnant women is undesirable.
  4. Iodine-containing preparations (potassium iodide solution) and iodine substitutes that promote the release of heparin by mast cells, which suppresses delayed-type hypersensitivity reactions, reduces thrombus formation and improves microcirculation.
  5. Short courses subcutaneous administration Heparin or Fraxiparin (better) - in severe cases.
  6. Antiallergic drugs (Fexofenadine, Loratidine).
  7. Angioprotectors that dilate small vessels and increasing their tone, reducing swelling and permeability of their walls, improving the rheological properties of blood and microcirculation (Pentoxifylline, Curantil, Vazonit, T rental, etc.).
  8. Vitamins “C” and “E”.
  9. Glucocorticoid drugs (Prednisolone, Metipred, Dexamethasone, Diprospan) are indicated for erythema nodosum, especially associated with sarcoidosis, in the presence of an intense inflammatory process and in case of insufficient effectiveness of the treatment. They can be prescribed in low doses even at any stage of pregnancy.
  10. Plasmapheresis or hemosorption - in case of particularly persistent and protracted course of the disease.

Local therapy

Local treatment is carried out with applications with Dimexin solution or Ichthyol solution, Dimexin gel in combination with Heparin, indovazin cream in combination with ointment or cream with corticosteroids - Beloderm containing betamethasone, Belogent (betamethasone with gentamicin), Belosalik (betamethasone with salicylic acid) .

After cupping acute manifestations In case of inflammation, it is possible to use physiotherapeutic procedures in the form of ozokerite applications, phonophoresis with liquid ointment (liniment) containing dibunol, with heparin, with lidase or hydrocortisone. Inductothermy, magnetic therapy, ultra-high frequency currents, laser treatment, etc. are also used.

Unified standards and treatment regimens for erythema nodosum have not been developed. The main drugs currently used are antibiotics. At the same time, their widespread use can contribute to the transition of an acute process to a chronic one. This is explained by the lack of influence of antibacterial agents and antibiotics on viruses and even on many strains of bacteria. On modern stage Treatment of both idiopathic and secondary diseases, unfortunately, is aimed primarily at reducing the severity of local inflammatory processes and reducing the duration of the disease.

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