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Sections Erythema Induratum (Nodular Vasculitis)
Overview
Presentation
DDx
Workup
Treatment
Medication
Questions & Answers
Media Gallery
References

Medication

Medication Summary

When treating erythema induratum (nodular vasculitis), combination therapy with isoniazid, ethambutol, and rifampicin should be continued for 9 months.^[31]Erythema induratum should begin to respond to therapy by 6 weeks.^[2]In addition, antipyretics and analgesics usually are required for symptomatic relief. After antituberculotic treatment for tuberculosis (TB), treatment for erythema induratum mirrors that of erythema nodosum (eg, naproxen, potassium iodide).^[31]

Class Summary

Anti-TB agents are used for empiric coverage of M tuberculosis.

Isoniazid (Nydrazid, Laniazid)

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Isoniazid is the best combination of effectiveness, low cost, and minor adverse effects. It is a first-line drug unless resistance or another contraindication is known. Therapeutic regimens of less than 6 months demonstrate an 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. Isoniazid is available as a syrup (50 mg/5 mL) and tablet (100 or 300 mg).

Rifampin (Rifadin, Rimactane)

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Rifampin is for use in combination with at least one other antituberculous drug; it inhibits DNA-dependent bacterial but not mammalian RNA polymerase. Cross-resistance may occur. Treat for 6-9 months or until 6 months have elapsed from conversion to sputum culture negativity. Rifampin is available as a capsule (150 mg or 300 mg) and powder for injection (600 mg).

Ethambutol (Myambutol)

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Ethambutol diffuses into actively growing mycobacterial cells, such as tubercle bacilli. It impairs cell metabolism by inhibiting the synthesis of 1 or more metabolites, which, in turn, causes cell death. No cross-resistance is demonstrated.

Mycobacterial resistance is frequent with previous therapy. In these patients, use in combination with second-line drugs not previously administered. Administer every 24 hours until permanent bacteriologic conversion and maximal clinical improvement is seen. Absorption is not significantly altered by food. Ethambutol is available as 100- and 400-mg tablets.

Pyrazinamide

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Pyrazinamide is a pyrazine analog of nicotinamide that may be bacteriostatic or bactericidal against M tuberculosis, depending on the concentration of drug attained at the site of infection; its mechanism of action is unknown. Administer for initial 2 months of a 6-month or longer treatment regimen for patients who are susceptible to the drug. Treat patients who are resistant to the drug with individualized regimens. Pyrazinamide is available as a 500-mg scored tablet.

Class Summary

These agents relieve lesional tenderness, arthralgia, and fever. Relief may occur in 24 hours. Most lesions completely subside within 10-14 days.

Potassium iodide (Thyro-Block, SSKI, Pima)

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Potassium iodide's mechanism of action is unknown, but it is known to enhance response by potentiating neutrophil activity. It is 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.

Class Summary

NSAIDs can be used for symptomatic pain relief and in cases of non–TB-associated erythema induratum.

Ibuprofen (Advil, Motrin, PediaCare Children's Pain Reliever/Fever Reducer IB)

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Ibuprofen inhibits the synthesis of prostaglandins in body tissues by inhibiting at least two cyclooxygenase (COX) isoenzymes, COX-1 and COX-2. It may inhibit chemotaxis, alter lymphocyte activity, decrease proinflammatory cytokine activity, and inhibit neutrophil aggregation; these effects may contribute to anti-inflammatory activity.

Naproxen (Aleve, Anaprox, Anaprox DS)

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Naproxen inhibits the synthesis of prostaglandins in body tissues by inhibiting at least two cyclooxygenase (COX) isoenzymes, COX-1 and COX-2. It may inhibit chemotaxis, alter lymphocyte activity, decrease proinflammatory cytokine activity, and inhibit neutrophil aggregation; these effects may contribute to anti-inflammatory activity.

Questions

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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.

Sections Erythema Induratum (Nodular Vasculitis)
Overview
Presentation
DDx
Workup
Treatment
Medication
Questions & Answers
Media Gallery
References

Erythema Induratum (Nodular Vasculitis) Medication

Medication Summary

Antitubercular Agents