Diagnostic Considerations

Erythema induratum (nodular vasculitis) must be distinguished from the following:

Erythema nodosum (EN) ^[2]: EN has a relatively short duration, develops rapidly, and mainly affects the anterior rather than posterior lower limb. EN lesions consist of tender, painful, scarlet or contusiform nodules that appear spontaneously and do not ulcerate. Histologically, septal panniculitis is seen. EN is generally more painful than erythema induratum.
Cutaneous polyarteritis nodosa (PAN): Cutaneous PAN presents as tender, erythematous, purpuric macules, papules, and nodules, often occurring in a livedoid pattern on the lower extremity. Histologically, cutaneous PAN is centered around small subcutaneous arteries rather than broader subcutaneous inflammation on many vessel types as in erythema induratum.
Tertiary syphilis: Gummas are usually unilateral and single or may appear as a small, distinct group of lesions.
Other infectious panniculitides (panniculitis caused by Mycobacterium massiliense ^[40])
Inflammatory panniculitides (eg, pancreatic panniculitis, lupus panniculitis, alpha-1 antitrypsin deficiency panniculitis, subcutaneous panniculitic T-cell lymphoma) ^[2]
Traumatic panniculitis (TP): TP occurs as one or a few tender or asymptomatic nodules. TP can occur at any site, the anterior leg (shin) being the most common location. Factitial panniculitis is a subtype of TP. Histologically, there is prominent fat necrosis but no vasculitis.

Differential Diagnoses

Cutaneous polyarteritis nodosa (PAN)
Erythema Nodosum
Inflammatory panniculitis
Other infectious panniculitis (eg, M massiliense)
Tertiary syphilis
Traumatic panniculitis

Workup

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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.