eMedicine Specialties > Dermatology > Diseases of the Vessels
Erythema Induratum (Nodular Vasculitis): Treatment & Medication
Updated: Mar 17, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
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Treatment
Medical Care
- Erythema induratum of Bazin is treated with antituberculous therapy. Antituberculosis monotherapy has been abandoned because of high resistance; a multidrug combination regimen is more widely accepted.
- Bed rest with systemic steroids may be indicated.
- Potassium iodide is sometimes applied, with high efficacy; however, this therapy requires caution when used in children or in patients with thyroid disease.
Medication
Combination therapy with isoniazid, ethambutol, and rifampicin should be continued for 9 months. In addition, antipyretics and analgesics are usually required.
Antituberculous agents
Used for empiric coverage for tubercle bacilli.
Isoniazid (Nydrazid, Laniazid)
Best combination of effectiveness, low cost, and minor adverse effects. First-line drug unless resistance or another contraindication is known. Therapeutic regimens of <6 mo demonstrate unacceptably high relapse rate. Coadministration of pyridoxine is recommended if peripheral neuropathies secondary to isoniazid therapy develop. Prophylactic doses of 6-50 mg of pyridoxine daily are recommended. Available as syr (50 mg/5 mL) and tab (100 or 300 mg).
Adult
5-10 mg/kg PO qd or divided bid; not to exceed 300 mg/d
Pediatric
10-20 mg/kg PO qd or divided bid; not to exceed 300 mg/d
Higher incidence of isoniazid-related hepatitis can occur with alcohol ingestion on daily basis; aluminum salts may decrease serum levels (administer 1-2 h before taking aluminum salts); may increase anticoagulant effects with coadministration; may inhibit metabolic clearance of benzodiazepines; carbamazepine toxicity or isoniazid hepatotoxicity may result from concurrent use (monitor carbamazepine concentrations and liver function); coadministration with cycloserine may increase CNS adverse effects (eg, dizziness); acute behavioral and coordination changes may occur with coadministration of disulfiram; coadministration with rifampin after halothane anesthesia may result in hepatotoxicity and hepatic encephalopathy; may inhibit hepatic microsomal enzymes and increase toxicity of hydantoin
Documented hypersensitivity; previous isoniazid-associated hepatic injury or other severe adverse reactions
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
Monitor patients with active chronic liver disease or severe renal dysfunction; periodic ophthalmologic examinations during therapy are recommended even when visual symptoms do not occur
Rifampin (Rifadin, Rimactane)
For use in combination with at least one other antituberculous drug; inhibits DNA-dependent bacterial but not mammalian RNA polymerase. Cross-resistance may occur. Treat for 6-9 mo or until 6 mo have elapsed from conversion to sputum culture negativity. Available as cap (150 mg or 300 mg) and powder for injection (600 mg).
Adult
10 mg/kg/d PO or 450-600 mg PO qd; not to exceed 600 mg qd
Pediatric
15-25 mg/kg PO qd
Induces microsomal enzymes, which may decrease effects of acetaminophen, oral anticoagulants, barbiturates, benzodiazepines, beta-blockers, chloramphenicol, oral contraceptives, corticosteroids, mexiletine, cyclosporine, digitoxin, disopyramide, estrogens, hydantoins, methadone, clofibrate, quinidine, dapsone, tazobactam, sulfonylureas, theophyllines, tocainide, and digoxin; blood pressure may increase with coadministration of enalapril; coadministration with isoniazid may result in higher rate of hepatotoxicity than with either agent alone (discontinue 1 or both agents if alterations in LFTs occur)
Documented hypersensitivity
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
Obtain CBC counts and baseline clinical chemistries prior to and throughout therapy; in liver disease, weigh benefits against risk of further liver damage; interruption of therapy and high-dose intermittent therapy are associated with thrombocytopenia that is reversible if therapy is discontinued as soon as purpura occurs; if treatment is continued or resumed after appearance of purpura, cerebral hemorrhage or death may occur
Body fluids (tears, saliva, urine) and feces may turn a red-orange color; warn patients of this side effect
Ethambutol (Myambutol)
Diffuses into actively growing mycobacterial cells, such as tubercle bacilli. Impairs cell metabolism by inhibiting synthesis of 1 or more metabolites, which, in turn, causes cell death. No cross-resistance demonstrated.
Mycobacterial resistance is frequent with previous therapy. Use in these patients in combination with second-line drugs not previously administered. Administer q24h until permanent bacteriologic conversion and maximal clinical improvement is seen. Absorption is not significantly altered by food. Available as 100- and 400-mg tab.
Adult
15-25 mg/kg PO qd
Pediatric
10-15 mg/kg PO qd
Aluminum salts may delay and reduce absorption (give several hours before or after ethambutol dose)
Documented hypersensitivity; optic neuritis (unless clinically indicated); children <12 y, owing to oculopathy
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
Reduce dose in impaired renal function; may have reversible visual adverse effects if promptly discontinued
Pyrazinamide
Pyrazine analog of nicotinamide that may be bacteriostatic or bactericidal against M tuberculosis, depending on concentration of drug attained at site of infection; mechanism of action is unknown. Administer for initial 2 mo of a 6-mo or longer treatment regimen for patients who are susceptible to drug. Treat patients who are resistant to drug with individualized regimens. Available as 500-mg scored tab.
Adult
15-30 mg/kg PO qd; not to exceed 2 g/d
Pediatric
20 mg/kg PO qd; not to exceed 2 g/d
None reported
Documented hypersensitivity; severe hepatic damage and acute gout;
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
Use only in combination with other effective antituberculous agents; inhibits renal excretion of urates; may result in hyperuricemia (usually asymptomatic); perform baseline serum uric acid determinations; discontinue drug if signs of hyperuricemia with acute gouty arthritis; perform baseline LFTs (closely monitor in liver disease); discontinue if signs of hepatocellular damage appear; caution in history of diabetes mellitus; CDC has recommended not to combine pyrazinamide and rifampin due to several reports of severe liver injury and death of patients
Antithyroid agents
These agents relieve lesional tenderness, arthralgia, and fever. Relief may occur in 24 h. Most lesions completely subside within 10-14 d.
Potassium iodide (Thyro-Block, SSKI, Pima)
Mechanism of action unknown, but potassium iodide is known to enhance response by potentiating neutrophil activity.
Not effective for all patients with erythema induratum. Patients who receive medication shortly after the initial onset of induratum respond more satisfactorily than those with chronic induratum.
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
Infants: 150-250 mg (3-6 gtt) PO tid
Children: Administer as in adults
Increases lithium toxicity by producing additive hypothyroid effects
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
More on Erythema Induratum (Nodular Vasculitis) |
| Overview: Erythema Induratum (Nodular Vasculitis) |
| Differential Diagnoses & Workup: Erythema Induratum (Nodular Vasculitis) |
 Treatment & Medication: Erythema Induratum (Nodular Vasculitis) |
| Follow-up: Erythema Induratum (Nodular Vasculitis) |
| Multimedia: Erythema Induratum (Nodular Vasculitis) |
| References |
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References
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Further Reading
Keywords
tuberculosis-associated erythema induratum, TB-associated erythema induratum, erythema induratum of Bazin
