History

A typical presentation of erythema induratum (nodular vasculitis) is recurrent crops of tender, violaceous nodules and plaques on the posterior lower limbs. The nodules usually evolve over several weeks and can eventually ulcerate and drain, ultimately healing with depressed scarring and postinflammatory hyperpigmentation. Leg edema also may be present.^[31]

A past or present history of infection with M tuberculosis at an extracutaneous site occurs in about 50% of patients; pulmonary tuberculosis (TB) is the most common foci of infection, with tuberculous cervical lymphadenitis being the next most common source. Erythema induratum and renal TB can also be associated.^[32]In a patient who presents with TB and nodular vasculitis, it is important to rule out HIV infection, as a variant of erythema induratum, nodular tuberculid, which features granulomatous vasculitis occurring at the dermohypodermal junction, has been noted in five patients with HIV disease.^{[33, 34]}

Although nodular vasculitis is classically associated with M tuberculosis infection, it also can occur due to infection with other agents, as well as from drugs. Non-TB infectious causes of erythema induratum include Nocardia, Pseudomonas, and Fusarium infections. Erythema induratum has also been reported in the setting of etanercept use in a patient with psoriasis.^[21]A case of erythema induratum was reported in an infant after BCG vaccination.^[35]

Nodular vasculitis also can present in the setting of noninfectious systemic illness. Nodular vasculitis has been reported in Crohn disease patients and the setting of renal cell carcinoma.^{[11, 36]}Painful peripheral neuropathy has also been associated with erythema induratum, with some reports of peripheral neuropathy being a presenting symptom of erythema induratum.^{[37, 38]}Addison disease that occurred during treatment for erythema induratum has been noted, and the authors of this report suggest that TB might have been the cause of the Addison disease.^[9]

Physical Examination

Erythema induratum lesions typically occur on the posterior or lateral lower limbs and may be either unilateral or bilateral, although the shins can sometimes be involved. Uncommonly, the trunk, buttocks, thighs, and arms can be involved; disseminated erythema induratum has also been reported.^[39]The nodules are concentrated around the lower third of the posterior lower limb, around the ankles. Crops of tender, erythematous-to-violaceous, variably scaly, 1- to 2-cm subcutaneous nodules may be observed, as demonstrated in the image below. The lesions resolve spontaneously with or without ulceration over several weeks/months, and they can heal with atrophic scarring and hyperpigmentation. Tenderness is usually present, but pain is variable and usually not excruciating, if present. The involved lower-limb sites may also show acrocyanosis.^[2]Patients with erythema induratum do not usually present with constitutional symptoms, except those related to their underlying disease. Peripheral neuropathy has also been reported in conjunction with erythema induratum.^{[37, 38]}

This patient exhibited tender, erythematous nodules confined to the lower third of the legs.

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Complications

The clinical course of erythema induratum is chronic, recurrent, and scarring, and, inadequately treated or untreated erythema induratum may result in prolonged disease, persistent and disfiguring ulcerations and scarring, and complications from underlying systemic TB or other infectious disease.^[3]

Differential Diagnoses

Motswaledi HM, Schulz EJ. Superficial thrombophlebitic tuberculide. Int J Dermatol. 2006 Nov. 45(11):1337-40. [QxMD MEDLINE Link].
James WD, Elston DM, Treat JR, Rosenbach MA, Neuhaus IM. Mycobacterial Diseases. Andrews' Diseases of the Skin. 13th ed. Elsevier; 2020. 329-331.
Wolff K, Johnson RA, Saavedra AP. The Skin in Immune Autoimmune, and Rheumatic Disorders. Fitzpatrick's Color Atlas and Synopsis of Clinical Dermatology. 7th ed. McGraw Hill Education; 2013. 364.
Mascaró JM Jr, Baselga E. Erythema induratum of bazin. Dermatol Clin. 2008 Oct. 26 (4):439-45, v. [QxMD MEDLINE Link].
Baselga E, Margall N, Barnadas MA, Coll P, de Moragas JM. Detection of Mycobacterium tuberculosis DNA in lobular granulomatous panniculitis (erythema induratum-nodular vasculitis). Arch Dermatol. 1997 Apr. 133 (4):457-62. [QxMD MEDLINE Link].
Segura S, Pujol RM, Trindade F, Requena L. Vasculitis in erythema induratum of Bazin: a histopathologic study of 101 biopsy specimens from 86 patients. J Am Acad Dermatol. 2008 Nov. 59 (5):839-51. [QxMD MEDLINE Link].
Westers-Attema A, van Tubergen A, Plasschaert H, van Marion AM, Frank J, Poblete-Gutiérrez P. Nodular vasculitis in systemic lupus erythematosus. Int J Dermatol. 2008 Nov. 47 Suppl 1:3-6. [QxMD MEDLINE Link].
Segura S, Pujol RM, Trindade F, Requena L. Vasculitis in erythema induratum of Bazin: a histopathologic study of 101 biopsy specimens from 86 patients. J Am Acad Dermatol. 2008 Nov. 59(5):839-51. [QxMD MEDLINE Link].
Brandão Neto RA, Carvalho JF. Erythema induratum of Bazin associated with Addison's disease: first description. Sao Paulo Med J. 2012. 130:405-8. [QxMD MEDLINE Link].
Kabuto M, Nakanishi G, Kimura H, Tanaka T, Fujimoto N. Erythema induratum (nodular vasculitis) associated with Takayasu arteritis. Eur J Dermatol. 2017 Aug 1. 27 (4):410-412. [QxMD MEDLINE Link].
Misago N, Narisawa Y. Erythema induratum (nodular vasculitis) associated with Crohns disease: a rare type of metastatic Crohns disease. Am J Dermatopathol. 2012 May. 34:325-9. [QxMD MEDLINE Link].
Pozdnyakova O, Garg A, Mahalingam M. Nodular vasculitis - a novel cutaneous manifestation of autoimmune colitis. J Cutan Pathol. 2008 Mar. 35 (3):315-9. [QxMD MEDLINE Link].
Khandpur S, Maharaja K. Inflammatory leg nodules: A clinical and investigational study. Natl Med J India. 2016 May-Jun. 29 (3):141-145. [QxMD MEDLINE Link].
Oshio A, Yoshii Y, Ono K, Hashimoto T, Satoh T. Erythema induratum of Bazin with anti-phospholipid antibodies. J Dtsch Dermatol Ges. 2015 Aug. 13 (8):810-1. [QxMD MEDLINE Link].
Fernandes SS, Carvalho J, Leite S, et al. Erythema induratum and chronic hepatitis C infection. J Clin Virol. 2009 Apr. 44(4):333-6. [QxMD MEDLINE Link].
Giménez-García R, Sánchez-Ramón S, Sánchez-Antolín G, Velasco Fernández C. Red fingers syndrome and recurrent panniculitis in a patient with chronic hepatitis C. J Eur Acad Dermatol Venereol. 2003 Nov. 17 (6):692-4. [QxMD MEDLINE Link].
Sakuma H, Niiyama S, Amoh Y, Katsuoka K. Chlamydophila pneumoniae Infection Induced Nodular Vasculitis. Case Rep Dermatol. 2011 Sep. 3 (3):263-7. [QxMD MEDLINE Link].
Campbell SM, Winkelmann RR, Sammons DL. Erythema Induratum Caused by Mycobacterium chelonei in an Immunocompetent Patient. J Clin Aesthet Dermatol. 2013 May. 6 (5):38-40. [QxMD MEDLINE Link].
Hattori M, Shimizu A, Hisada T, Fukumoto T, Ishikawa O. Erythema Induratum in a Patient with Pulmonary Mycobacterium avium Infection. Acta Derm Venereol. 2016 Jun 15. 96 (5):705-6. [QxMD MEDLINE Link].
Romero JJ, Herrera P, Cartelle M, Barba P, Tello S, Zurita J. Panniculitis caused by Mycobacterium monacense mimicking erythema induratum: a case in Ecuador. New Microbes New Infect. 2016 Mar. 10:112-5. [QxMD MEDLINE Link].
Park SB, Chang IK, Im M, Lee Y, Kim CD, Seo YJ, et al. Nodular Vasculitis That Developed during Etanercept (Enbrel) Treatment in a Patient with Psoriasis. Ann Dermatol. 2015 Oct. 27 (5):605-7. [QxMD MEDLINE Link].
Wolf D, Ben-Yehuda A, Okon E, Naparstek Y. Nodular vasculitis associated with propylthiouracil therapy. Cutis. 1992 Apr. 49 (4):253-5. [QxMD MEDLINE Link].
Baba N, Takashima W, Tokuriki A, Ameshima S, Hasegawa M. Erythema induratum of Bazin which occurred after tumor necrosis factor antagonist therapy. J Dermatol. 2017 May. 44 (5):e87-e88. [QxMD MEDLINE Link].
Vena GA, Apruzzi D, Vestita M, Panaro M, Carpagnano S, Filannino R, et al. Recurrence of erythema induratum of Bazin in a patient under chemotherapy for breast cancer. New Microbiol. 2011 Jul. 34 (3):331-3. [QxMD MEDLINE Link].
Sharon V, Goodarzi H, Chambers CJ, Fung MA, Armstrong AW. Erythema induratum of Bazin. Dermatol Online J. 2010 Apr 15. 16 (4):1. [QxMD MEDLINE Link].
Cho KH, Lee DY, Kim CW. Erythema induratum of Bazin. Int J Dermatol. 1996 Nov. 35 (11):802-8. [QxMD MEDLINE Link].
Thoo CH, Graf N, Hogan P. Erythema induratum in a Kenyan child. Australas J Dermatol. 2008 Aug. 49 (3):156-8. [QxMD MEDLINE Link].
Wee E, Kelly RI. Treatment of nodular vasculitis with colchicine. Australas J Dermatol. 2017 Aug. 58 (3):e79-e82. [QxMD MEDLINE Link].
Ho CK, Ho MH, Chong LY. Cutaneous tuberculosis in Hong Kong: an update. Hong Kong Med J. 2006 Aug. 12(4):272-7. [QxMD MEDLINE Link].
Lighter J, Tse DB, Li Y, Borkowsky W. Erythema induratum of Bazin in a child: evidence for a cell-mediated hyper-response to Mycobacterium tuberculosis. Pediatr Infect Dis J. 2009 Apr. 28 (4):326-8. [QxMD MEDLINE Link].
Gilchrist H, Patterson JW. Erythema nodosum and erythema induratum (nodular vasculitis): diagnosis and management. Dermatol Ther. 2010 Jul. 23(4):320-7. [QxMD MEDLINE Link].
Daher Ede F, Silva Junior GB, Pinheiro HC, Oliveira TR, Vilar Mdo L, Alcantara KJ. Erythema induratum of Bazin and renal tuberculosis: report of an association. Rev Inst Med Trop Sao Paulo. 2004 Sep-Oct. 46(5):295-8. [QxMD MEDLINE Link].
Friedman PC, Husain S, Grossman ME. Nodular tuberculid in a patient with HIV. J Am Acad Dermatol. 2005 Aug. 53(2 Suppl 1):S154-6. [QxMD MEDLINE Link].
Varshney A, Goyal T. Incidence of various clinico-morphological variants of cutaneous tuberculosis and HIV concurrence: a study from the Indian subcontinent. Ann Saudi Med. 2011 Mar-Apr. 31(2):134-9. [QxMD MEDLINE Link]. [Full Text].
Inoue T, Fukumoto T, Ansai S, Kimura T. Erythema induratum of Bazin in an infant after Bacille Calmette-Guerin vaccination. J Dermatol. 2006 Apr. 33(4):268-72. [QxMD MEDLINE Link].
Sharon V, Goodarzi H, Chambers CJ, Fung MA, Armstrong AW. Erythema induratum of Bazin. Dermatol Online J. 2010 Apr 15. 16(4):1. [QxMD MEDLINE Link].
Silva MT, Antunes SL, Rolla VC, Galhardo MC, Sant'ana FM, do Valle AF. Distal painful peripheral neuropathy associated with erythema induratum of Bazin. Eur J Neurol. 2006 Dec. 13(12):e5-6. [QxMD MEDLINE Link].
Zakeri K, Oganesyan G, Lee RA, Lillis JV. Erythema induratum of Bazin presenting as peripheral neuropathy. Cutis. 2015 Sep. 96 (3):E1-4. [QxMD MEDLINE Link].
Teramura K, Fujimoto N, Nakanishi G, Shigeta M, Tanaka T. Disseminated erythema induratum of Bazin. Eur J Dermatol. 2014 Oct 21. [QxMD MEDLINE Link].
Park SH, Chae JK, Kim EJ, Park K. A case of panniculitis caused by Mycobacterium massiliense mimicking erythema induratum. Br J Dermatol. 2015 Jul. 173 (1):235-8. [QxMD MEDLINE Link].
Jacinto SS, Nograles KB. Erythema induratum of bazin: role of polymerase chain reaction in diagnosis. Int J Dermatol. 2003 May. 42(5):380-1. [QxMD MEDLINE Link].
Chen YH, Yan JJ, Chao SC, Lee JY. Erythema induratum: a clinicopathologic and polymerase chain reaction study. J Formos Med Assoc. 2001 Apr. 100(4):244-9. [QxMD MEDLINE Link].
Schneider JW, Jordaan HF, Geiger DH, Victor T, Van Helden PD, Rossouw DJ. Erythema induratum of Bazin. A clinicopathological study of 20 cases and detection of Mycobacterium tuberculosis DNA in skin lesions by polymerase chain reaction. Am J Dermatopathol. 1995 Aug. 17(4):350-6. [QxMD MEDLINE Link].
Center for Disease Control and Prevention. Fact Sheet: Testing and Diagnosis. Tuberculosis (TB). Available at http://www.cdc.gov/tb/publications/factsheets/testing/igra.htm. Accessed: January 30, 2013.
Angus J, Roberts C, Kulkarni K, Leach I, Murphy R. Usefulness of the QuantiFERON test in the confirmation of latent tuberculosis in association with erythema induratum. Br J Dermatol. 2007 Dec. 157(6):1293-4. [QxMD MEDLINE Link].
Sim JH, Whang KU. Application of the QuantiFERON®-TB Gold test in Erythema Induratum. J Dermatolog Treat. 2012 Sep 19. [QxMD MEDLINE Link].
Cusack CA, Fanelli M. Panniculitis. Legwohl MG, Berth-Jones J, Heymann WR, Coulson I, eds. Treatment of Skin Disease. 4th ed. Elsevier Saunders; 2014. 526.
Schulz EJ, Whiting DA. Treatment of erythema nodosum and nodular vasculitis with potassium iodide. Br J Dermatol. 1976 Jan. 94 (1):75-8. [QxMD MEDLINE Link].
Horio T, Imamura S, Danno K, Ofuji S. Potassium iodide in the treatment of erythema nodosum and nodular vasculitis. Arch Dermatol. 1981 Jan. 117 (1):29-31. [QxMD MEDLINE Link].
Kieu V, Williams R, Hill P, Kelly R. Clofazimine-induced enteropathy in treatment-resistant nodular vasculitis. Australas J Dermatol. 2012 May. 53 (2):141-4. [QxMD MEDLINE Link].
Shaffer N, Kerdel FA. Nodular vasculitis (erythema induratum): treatment with auranofin. J Am Acad Dermatol. 1991 Aug. 25 (2 Pt 2):426-9. [QxMD MEDLINE Link].
Taverna JA, Radfar A, Pentland A, Poggioli G, Demierre MF. Case reports: nodular vasculitis responsive to mycophenolate mofetil. J Drugs Dermatol. 2006 Nov-Dec. 5 (10):992-3. [QxMD MEDLINE Link].
Mei X, Zhao J. Successful treatment of erythema induratum with topical application of antituberculous drugs: A case report. Medicine (Baltimore). 2017 Dec. 96 (49):e9010. [QxMD MEDLINE Link].

Media Gallery

This patient exhibited tender, erythematous nodules confined to the lower third of the legs.
Vasculitis and granulomatous inflammation in the dermis and subcutaneous fat tissues.
Evidence of panniculitis exhibiting lobular, granulomatous, and lymphohistiocytic inflammation.
A positive Mantoux test reaction in a patient with erythema induratum.

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Author

Esther A Balogh, MD Research Fellow, Center for Dermatology Research, Department of Dermatology, Wake Forest University School of Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

William W Huang, MD, MPH, FAAD Associate Professor and Residency Program Director, Department of Dermatology, Wake Forest Baptist Health, Wake Forest University School of Medicine

William W Huang, MD, MPH, FAAD is a member of the following medical societies: American Academy of Dermatology, Association of Professors of Dermatology, Dermatology Foundation, Medical Dermatology Society, North Carolina Medical Society, Women's Dermatologic Society

Disclosure: Research PI for Sponsored Trial for: Gilead; Genentech;.

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.

Lester F Libow, MD Dermatopathologist, South Texas Dermatopathology Laboratory

Lester F Libow, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, Texas Medical Association

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: Received income in an amount equal to or greater than $250 from: Elsevier; WebMD<br/>Served as a speaker for various universities, dermatology societies, and dermatology departments.

Additional Contributors

Jean-Hilaire Saurat, MD Chair, Professor, Department of Dermatology, University of Geneva, Switzerland

Jean-Hilaire Saurat, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Noah S Scheinfeld, JD, MD, FAAD † Assistant Clinical Professor, Department of Dermatology, Weil Cornell Medical College; Consulting Staff, Department of Dermatology, St Luke's Roosevelt Hospital Center, Beth Israel Medical Center, New York Eye and Ear Infirmary; Assistant Attending Dermatologist, New York Presbyterian Hospital; Assistant Attending Dermatologist, Lenox Hill Hospital, North Shore-LIJ Health System; Private Practice

Noah S Scheinfeld, JD, MD, FAAD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous previous authors, Beom Joon Kim, MD, and Kwang-Hyun Cho, MD, to the development and writing of this article.