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Erythema Elevatum Diutinum Clinical Presentation

  • Author: Firas G Hougeir, MD; Chief Editor: William D James, MD  more...
Updated: Jun 03, 2016


Patients with erythema elevatum diutinum (EED) usually present with persistent, firm lesions on the extensor surfaces of their skin, especially over the joints. These lesions are most often nodules and round or oval plaques (see image below). However, on rare occasions, blisters and ulcers may also appear.

Nodular lesions on the knees of a patient with ery Nodular lesions on the knees of a patient with erythema elevatum diutinum.

The color of the lesions progresses over time from yellow or pinkish to red, purple, or brown. In addition to the color changes, patients may describe the lesions as increasing in number and size over time. They may also note that the lesions enlarge during the day and return to their previous size overnight.[9]

The lesions can be completely asymptomatic, painful, or cause a sensation of burning or itching. These symptoms can be exacerbated by cold.

The general health of the patient may be otherwise excellent, although a history of arthralgia is found relatively often with erythema elevatum diutinum.



Upon physical examination, erythema elevatum diutinum lesions are generally found symmetrically on the extensor surfaces of the skin, especially over the joints.[10]

Clinical studies show a preference for the extensor surfaces of the hands, the wrists, the elbows, the ankles, the Achilles tendons, the fingers, and the toes (see image below).

Plaques and papular lesions on the wrists and the Plaques and papular lesions on the wrists and the dorsum of the hands and the digits of a patient with erythema elevatum diutinum.

The buttocks, the face, and the ears as well as the palms, the soles, the legs, the forearms, and the genitals may be involved[11] ; however, the trunk is usually spared.

The lesions usually feel firm and are freely movable over the underlying tissue, except when on the palms and the soles.[11]

Their surface is generally smooth and sometimes slightly scaly.

Crusting and/or bleeding, although uncommon, have been noted.

Several studies have shown an association of erythema elevatum diutinum with ocular abnormalities, including nodular scleritis, panuveitis, autoimmune keratolysis, and peripheral keratitis.[12, 13] Therefore, attention should be given to ocular symptoms and eye examination findings.



The cause of erythema elevatum diutinum (EED) has not yet been definitively established.

Disorders that have been associated with erythema elevatum diutinum include recurrent bacterial infections (especially streptococcal), viral infections (including hepatitis B or HIV),[14] rheumatologic disease (in the Bury type), lupus erythematosus, and B-cell lymphoma.[15, 16, 17, 18]

In recent years, several reports, including the 2 largest clinical studies completed on erythema elevatum diutinum, have suggested hematologic disease as the most common factor associated with erythema elevatum diutinum.

Monoclonal gammopathies, especially IgA monoclonal gammopathy, have been found in a significant number of patients in several studies.

Erythema elevatum diutinum has also been reported after the administration of erythropoietin.[19]

Contributor Information and Disclosures

Firas G Hougeir, MD Staff Dermatologist, Private Practice, Georgia

Firas G Hougeir, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.


James A Yiannias, MD Associate Professor of Dermatology, Associate Dean, Mayo School of Graduate Medical Education, Mayo Foundation for Medical Education and Research; Vice Chair, Medical Division, Department of Dermatology, Mayo Clinic Scottsdale

James A Yiannias, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Specialty Editor Board

Richard P Vinson, MD Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster 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, Texas Medical Association, Association of Military Dermatologists, Texas Dermatological Society

Disclosure: Nothing to disclose.

Christen M Mowad, MD Professor, Department of Dermatology, Geisinger Medical Center

Christen M Mowad, MD is a member of the following medical societies: Alpha Omega Alpha, Noah Worcester Dermatological Society, Pennsylvania Academy of Dermatology, American Academy of Dermatology, Phi Beta Kappa

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Carrie L Kovarik, MD Assistant Professor of Dermatology, Dermatopathology, and Infectious Diseases, University of Pennsylvania School of Medicine

Carrie L Kovarik, MD is a member of the following medical societies: Alpha Omega Alpha

Disclosure: Nothing to disclose.

  1. Hutchinson J. On two remarkable cases of symmetrical purple congestion of the skin in patches, with induration. Br J Dermatol. 1880. 1:10.

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Plaques and papular lesions on the wrists and the dorsum of the hands and the digits of a patient with erythema elevatum diutinum.
Nodular lesions on the knees of a patient with erythema elevatum diutinum.
Fibrinoid changes in dermal blood vessels with polymorphonuclear neutrophil infiltration.
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