eMedicine Specialties > Dermatology > Diseases of the Subcutaneous Tissue

Subacute Nodular Migratory Panniculitis (Vilanova Disease): Treatment & Medication

Author: Sarah M Sawyer, MD, Staff Physician, Department of Dermatology, University of Alabama School of Medicine
Coauthor(s): Daniel Davis, MD, Associate Professor, Departments of Dermatology, Otolaryngology, and Pathology, University of Arkansas for Medical Sciences; Vlada Groysman, MD, Staff Physician, Department of Dermatology, University of Alabama School of Medicine
Contributor Information and Disclosures

Updated: Mar 19, 2009

Treatment

Medical Care

Treatment with intralesional steroids may be effective. Otherwise, systemic medications, such as potassium iodide or dapsone, are used.8,9,10

Surgical Care

No surgical treatment is indicated.

Consultations

Consult a dermatologist to perform a skin biopsy.

Diet

No specific dietary requirements are indicated.

Activity

Activity is ad lib, taking care to avoid trauma to affected areas.

Medication

Therapy for this condition is not mandatory, and several factors should be weighed prior to treatment. The factors that should be considered include the extent to which the disease disturbs the patient and the potential adverse effects of the medication.

Iodine products

Treatment with intralesional steroids may be effective. Otherwise, systemic medications, such as potassium iodide or dapsone, are used.


Potassium iodide (SSKI, Pima)

Most commonly used therapy for this condition. Works via potassium concentration in granulomas, which releases heparin and inhibits delayed-type hypersensitivity response. Response should be seen in all patients in 2-3 wk.

Adult

300-500 mg PO (6-10 gtt) tid
Liquid supersaturated potassium iodide (SSKI): 3 gtt tid in juice and increase by 1 gtt tid; not to exceed 15 gtt tid

Pediatric

150-250 mg (3-6 gtt) PO tid

Increases lithium toxicity by producing additive hypothyroid effects; may increase toxicity of digoxin

Documented hypersensitivity; pulmonary edema; bronchitis; tuberculosis; hyperkalemia

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Prolonged use may result in hypothyroidism; caution in renal failure and GI obstruction; iododerma, coryza, cough, nausea, rhinorrhea, and parotiditis may occur

Leprostatic agents

These agents may have immunomodulatory effects. Dapsone has been reported as being a successful treatment of subacute migratory panniculitis, but treatment is not well established.


Dapsone (Avlosulfon)

Bactericidal and bacteriostatic against mycobacteria; mechanism of action is similar to that of sulfonamides where competitive antagonists of PABA prevent formation of folic acid, inhibiting bacterial growth.

Adult

50 mg PO qd initially; increase to 200-300 mg qd

Pediatric

Not established

Trimethoprim, probenecid, and folic acid antagonists (eg, pyrimethamine, methotrexate) increase drug levels; activated charcoal, PABA, and rifampin decrease levels; sulfonamides and hydroxychloroquine increase hemolysis

Absolute: hypersensitivity
Relative: G-6-PD deficiency (especially in African Americans, persons of Middle Eastern heritage, and Asians), significant cardiopulmonary or hematologic disease, sulfa allergy (cautious use in patients with sulfa allergy may be attempted; cross-reactivity is relatively rare and mild)

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Hemolytic anemia is dose related and occurs to some degree in all patients taking dapsone; older RBCs are more susceptible; most patients have 2 g/dL drop in hemoglobin with reequilibration at 1 g/dL below count; reticulocyte count may be used to monitor bounce-back; G-6-PD-deficient patients more affected
Methemoglobinemia is dose related; degree of cyanosis not predictive of degree of methemoglobinemia; patients with significant cardiopulmonary disease or low baseline hemoglobin levels may not be able to tolerate low levels of methemoglobin; vitamin E at 800 IU/d and cimetidine at 400 mg tid has been shown to provide a small amount of protection from formation of methemoglobin and hemolysis
Agranulocytosis is idiosyncratic; mechanism not known; occurs 1 in 240-425 patients; has occurred as early as 3 wk; all cases developed within 12 wk; fever, pharyngitis, sepsis; mortality rate 50%; if promptly discontinued, recovery in 7-14 d; granulocyte colony-stimulating factor may speed recovery
Distal motor neuropathy with some sensory involvement can occur; distal motor weakness of hands and legs; wasting of hand muscles; most patients recover completely with discontinuation; recovery may take from 2 wk to 2 y; mechanism of neuropathy unknown
Permanent retinal damage has been reported with overdosage; thought to be due to hypoxia
Acute psychosis can occur, usually in leprosy patients
GI upset minimized if taken with food; primary hepatocellular hepatitis, cholestatic hepatitis, hypoalbuminemia, gall bladder perforation, and pancreatitis reported
Dapsone hypersensitivity syndrome is a mononucleosislike eruption with fever; skin eruption has ranged from maculopapular to TEN; hepatitis; peripheral eosinophilia; fatalities reported; treatment with steroids tried but due to its rarity, not proven effective
Cutaneous hypersensitivity eruptions include maculopapular rash, EM, or TEN (rare)
Photosensitivity is reported
Carcinogenesis reported in animal studies (slight increase in malignancies if taken for 2 y or more); not documented in humans


Triamcinolone (Aristocort, Aristospan)

Decreases inflammation by suppressing migration of PMN leukocytes and reversing capillary permeability. Intralesional injections may be used for localized skin disorder.

Adult

3-10 mg/mL intralesionally; may repeat in 4-6 wk

Pediatric

<12 years: Not established
>12 years: Administer as in adults

Documented hypersensitivity; fungal, viral, and bacterial skin infections

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

A percentage of drug may be absorbed systemically

More on Subacute Nodular Migratory Panniculitis (Vilanova Disease)

Overview: Subacute Nodular Migratory Panniculitis (Vilanova Disease)
Differential Diagnoses & Workup: Subacute Nodular Migratory Panniculitis (Vilanova Disease)
Treatment & Medication: Subacute Nodular Migratory Panniculitis (Vilanova Disease)
Follow-up: Subacute Nodular Migratory Panniculitis (Vilanova Disease)
References
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References

  1. Bafverstedt B. Not Available. Acta Derm Venereol. 1954;34(3):181-93. [Medline].

  2. Vilanova X, Pinol Aguade J. Subacute Nodular Migratory Panniculitis. Br J Dermatol. Feb 1959;71(2):45-50. [Medline].

  3. de Almeida Prestes C, Winkelmann RK, Su WP. Septal granulomatous panniculitis: comparison of the pathology of erythema nodosum migrans (migratory panniculitis) and chronic erythema nodosum. J Am Acad Dermatol. Mar 1990;22(3):477-83. [Medline].

  4. Fine RM, Meltzer HD. Chronic erythema nodosum. Arch Dermatol. Jul 1969;100(1):33-8. [Medline].

  5. Lee UH, Yang JH, Chun DK, Choi JC. Erythema nodosum migrans. J Eur Acad Dermatol Venereol. Jul 2005;19(4):519-20. [Medline].

  6. Requena L, Requena C. Erythema nodosum. Dermatol Online J. Jun 2002;8(1):4. [Medline]. [Full Text].

  7. Ross M, White GM, Barr RJ. Erythematous plaque on the leg. Vilanova's disease (subacute nodular migratory panniculitis). Arch Dermatol. Dec 1992;128(12):1644-5, 1647. [Medline].

  8. Perry HO, Winkelmann RK. Subacute nodular migratory panniculitis. Arch Dermatol. Feb 1964;89:170-9. [Medline].

  9. Schulz EJ, Whiting DA. Treatment of erythema nodosum and nodular vasculitis with potassium iodide. Br J Dermatol. Jan 1976;94(1):75-8. [Medline].

  10. Sterling JB, Heymann WR. Potassium iodide in dermatology: a 19th century drug for the 21st century-uses, pharmacology, adverse effects, and contraindications. J Am Acad Dermatol. Oct 2000;43(4):691-7. [Medline].

  11. Montgomery H, O'Leary P, Barker N. Nodular vascular diseases of the legs. JAMA. 1945;128:335-41.

  12. Niemi KM, Forstrom L, Hannuksela M, Mustakallio KK, Salo OP. Nodules on the legs. A clinical, histological and immunohistological study of 82 patients representing different types of nodular panniculitis. Acta Derm Venereol. 1977;57(2):145-54. [Medline].

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Further Reading

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Keywords

Vilanova disease, subacute nodular migratory panniculitis, chronic erythema nodosum, erythema nodosum migrans

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Contributor Information and Disclosures

Author

Sarah M Sawyer, MD, Staff Physician, Department of Dermatology, University of Alabama School of Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Daniel Davis, MD, Associate Professor, Departments of Dermatology, Otolaryngology, and Pathology, University of Arkansas for Medical Sciences
Disclosure: Nothing to disclose.

Vlada Groysman, MD, Staff Physician, Department of Dermatology, University of Alabama School of Medicine
Vlada Groysman, MD is a member of the following medical societies: American Academy of Dermatology, Medical Dermatology Society, and Women's Dermatologic Society
Disclosure: Nothing to disclose.

Medical Editor

Sungnack Lee, MD, Vice President of Medical Affairs, Professor, Department of Dermatology, Ajou University School of Medicine, Korea
Sungnack Lee, MD is a member of the following medical societies: American Dermatological Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Richard P Vinson, MD, Assistant Clinical Professor, Department of Dermatology, Texas Tech University School of Medicine; Consulting Staff, Mountain View Dermatology, PA
Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Christen M Mowad, MD, Associate Professor, Department of Dermatology, Geisinger Medical Center
Christen M Mowad, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, and Phi Beta Kappa
Disclosure: Nothing to disclose.

CME Editor

Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University
Catherine Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

William D James, MD, Paul R Gross Professor of Dermatology, University of Pennsylvania School of Medicine; Vice-Chair, Program Director, Department of Dermatology, University of Pennsylvania Health System
William D James, MD is a member of the following medical societies: American Academy of Dermatology and Society for Investigative Dermatology
Disclosure: elsevier Royalty Other; american college of physicians Honoraria Other

 
 
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