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Woman coughing, possibly showing signs of infection linked to erythema nodosum

Causes of Erythema Nodosum

Erythema Nodosum, Health Conditions /

Causes of Erythema Nodosum The causes of erythema nodosum are varied, and in many cases, no single cause is ever found. However, erythema nodosum is often a reaction to infection, inflammation, or medication. Identifying the cause helps doctors decide whether further treatment or investigation is necessary. Infections Infectious causes are among the most common, particularly: Streptococcal throat infections – Often seen in children and young adults Tuberculosis (TB) – A major cause in regions like South Africa, especially in rural or high-prevalence areas HIV and associated infections – May trigger inflammatory reactions Fungal infections – Such as histoplasmosis or coccidioidomycosis in some regions Yersinia enterocolitica – A bacterial gut infection sometimes linked to erythema nodosum Inflammatory and Autoimmune Conditions Several chronic diseases can trigger the condition: Sarcoidosis – A common cause in adults, especially when combined with symptoms like cough and swollen lymph nodes Inflammatory bowel disease – Both Crohn’s disease and ulcerative colitis are linked Behçet’s disease – A rare condition that may present with ulcers, joint pain, and skin lesions Medications Some medications can provoke a hypersensitive reaction: Sulphonamides Oral contraceptives Penicillins Non-steroidal anti-inflammatory drugs (NSAIDs) Drug-related erythema nodosum often resolves once the medication is stopped. Pregnancy Hormonal changes during pregnancy may also trigger episodes of erythema nodosum, especially in the first trimester. Causes of Erythema Nodosum In South Africa In South Africa, TB is a leading cause. Erythema nodosum may be the first visible sign, especially in patients who have not yet shown respiratory symptoms. HIV-positive individuals are also more prone to skin-related inflammatory reactions. Doctors in South Africa should consider TB screening and HIV testing in patients presenting with unexplained erythema nodosum. Understanding the causes of erythema nodosum helps guide tests, treatment, and decisions about whether to investigate for underlying infections or autoimmune disorders. [Next: Symptoms of Erythema Nodosum →]

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Illustration showing pain, redness, swelling, and numbness in hands

Symptoms of Erythema Nodosum

Erythema Nodosum, Health Conditions /

Symptoms of Erythema Nodosum The symptoms of erythema nodosum are mostly limited to the skin but may be accompanied by systemic signs depending on the underlying cause. Erythema nodosum typically begins with general flu-like symptoms, followed by the appearance of painful red lumps on the legs. Skin Symptoms Tender red nodules – Usually located on the front of the shins, but may also appear on the thighs, arms, or trunk Symmetrical distribution – Lesions typically appear on both legs Size – Nodules range from 1 to 5 cm in diameter Colour changes – Lesions start red, then become bluish or purple before fading to yellow or green like a bruise Pain or tenderness – Especially when touched or with pressure New nodules may appear for one to two weeks, and each lesion lasts about two weeks before resolving. General Symptoms Many people experience: Fever Fatigue Joint pain, especially in the knees or ankles Swollen ankles or legs Headache or malaise These systemic symptoms often occur before or alongside the skin eruption. They may be mistaken for a viral infection or flu in the early stages. Duration The full course of erythema nodosum usually lasts between three and six weeks. In some cases, the condition recurs, particularly if the trigger isn’t identified or resolved. In Children Children may have milder lesions, but they often present with fever, sore throat, and joint pain. A streptococcal infection is the most common cause in this age group. Symptoms of Erythema Nodosum In South Africa In South Africa, clinicians should be alert for TB in any patient presenting with erythema nodosum and constitutional symptoms like fever or weight loss. Patients with HIV may also show more severe symptoms or slower resolution. Prompt recognition of the symptoms of erythema nodosum allows doctors to manage discomfort while identifying any underlying medical cause. This ensures both symptom relief and appropriate long-term care. [Next: Diagnosis of Erythema Nodosum→]

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Diagnosis of Erythema Nodosum

Diagnosis of Erythema Nodosum

Erythema Nodosum, Health Conditions /

Diagnosis of Erythema Nodosum The diagnosis of erythema nodosum is usually based on clinical examination and supported by investigations to identify the underlying cause. Because erythema nodosum is a skin reaction, not a disease on its own, doctors must determine what triggered it to offer appropriate treatment. Clinical Assessment Doctors begin with: A visual examination of the lesions Noting their size, colour, symmetry, and tenderness Asking about recent infections, medications, or travel Reviewing systemic symptoms such as fever, joint pain, sore throat, or weight loss The appearance of painful, red nodules on the shins in a symmetrical pattern is often enough to suspect erythema nodosum. However, identifying the cause is critical to prevent recurrence. Laboratory Investigations Several blood and diagnostic tests may be ordered to uncover a possible trigger: Full blood count (FBC) – Looks for elevated white cells or inflammation Erythrocyte sedimentation rate (ESR) / C-reactive protein (CRP) – Raised levels support the diagnosis of an inflammatory condition Anti-streptolysin O (ASO) titre – Detects a recent streptococcal infection HIV test – Especially important in South Africa due to the high prevalence Tuberculosis (TB) screening, including: Chest X-ray Sputum test or GeneXpert Tuberculin skin test (TST) or IGRA Additional Tests Depending on symptoms and suspected causes: Throat swab, if sore throat is present Stool cultures, if gastrointestinal symptoms are noted Chest CT scan, in cases where sarcoidosis is suspected Colonoscopy, if inflammatory bowel disease is suspected Pregnancy test, if relevant Skin Biopsy In uncertain or atypical cases, a skin biopsy may be performed. This can confirm panniculitis (inflammation of fat tissue) and help rule out other forms of skin disease such as vasculitis, cellulitis, or erythema induratum. Diagnosis of Erythema Nodosum In South Africa In South Africa, TB testing is often prioritised. Erythema nodosum may be the first symptom of a previously undiagnosed TB infection. In areas where access to biopsy or lab testing is limited, clinical diagnosis supported by chest X-ray and TB symptoms is commonly used. The diagnosis of erythema nodosum should be thorough, not just to confirm the condition but to uncover the underlying cause. This ensures faster recovery and reduces the risk of repeat episodes. [Next: Treatment of Erythema Nodosum →]

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Medical professional examining erythema nodosum on a patient’s arm

Treatment of Erythema Nodosum

Erythema Nodosum, Health Conditions /

Treatment of Erythema Nodosum The treatment of erythema nodosum focuses on reducing inflammation, relieving pain, and addressing the underlying cause. Erythema nodosum usually resolves on its own within three to six weeks, but treatment helps manage symptoms and prevent recurrence. Rest and Supportive Care For most patients, the main treatment includes: Rest and leg elevation, especially during painful flare-ups Cool compresses, to reduce inflammation Compression stockings, to support circulation and minimise swelling Avoiding prolonged standing or walking, especially in the acute phase These basic steps can make a significant difference in comfort levels. Pain and Inflammation Relief To ease symptoms: Doctors commonly prescribe non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen. Paracetamol can be used for fever or general discomfort In severe cases, doctors may prescribe oral corticosteroids like prednisone for short-term use—but only if there is no infection, such as tuberculosis Doctors should never start corticosteroids until they have ruled out infections like TB, as these medications can worsen the disease. Treating the Underlying Cause Identifying and addressing the trigger is crucial: Antibiotics, for streptococcal infections Anti-TB medication, if tuberculosis is confirmed Doctors stop the responsible medication if they suspect a drug-induced reaction Doctors prescribe immunosuppressants only when erythema nodosum is linked to autoimmune diseases like sarcoidosis or inflammatory bowel disease, and even then, only in rare cases. Recurrent Cases For patients with frequent episodes: Long-term NSAID therapy may be considered under supervision Colchicine or potassium iodide is occasionally used Antiviral or antimicrobial suppression may help if the cause is infectious Lifestyle adjustments, such as managing weight and avoiding known triggers, may also reduce recurrence. Treatment of Erythema Nodosum In South Africa In South Africa, TB-related erythema nodosum is common. Patients may start TB treatment based on chest X-ray and clinical suspicion. Public hospitals often provide NSAIDs and basic wound care supplies, while doctors reserve corticosteroids for non-infectious cases after thorough evaluation. Doctors often treat erythema nodosum straightforwardly, tailoring the treatment to each individual. Identifying and resolving the underlying cause leads to a faster recovery and prevents repeated flare-ups. [Next: Complications of Erythema Nodosum →]

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Illustration showing inflamed and painful patches on legs due to erythema nodosum

Complications of Erythema Nodosum

Erythema Nodosum, Health Conditions /

Complications of Erythema Nodosum The complications of erythema nodosum are generally mild, especially when the condition is short-lived and the cause is treated. However, erythema nodosum can lead to physical, emotional, and sometimes systemic issues if it becomes chronic or is associated with an underlying illness. Pain and Reduced Mobility Painful nodules on the legs can make walking or standing difficult. This may result in: Reduced physical activity Difficulty at work or school Temporary reliance on mobility aids in severe cases In children and working adults, this may cause significant disruption to daily routines. Recurrence Some individuals experience recurrent erythema nodosum, particularly when the trigger is not identified or remains untreated. This may occur: During future infections With certain medications In chronic autoimmune or inflammatory diseases Repeated episodes can lead to frustration and reduced quality of life. Skin Discolouration and Scarring Although erythema nodosum typically resolves without scarring, some patients may develop: Bruise-like discolouration for weeks after the lesions fade Hyperpigmentation, especially in individuals with darker skin Thickened or hardened skin, rarely, if inflammation was deep or prolonged Emotional Impact Visible, painful lesions can cause embarrassment, particularly when they affect the legs in warm weather. Patients may feel: Self-conscious about their appearance Anxious about the possibility of recurrence Frustrated by delayed diagnosis or lack of treatment Support and education about the condition help reduce stress and encourage compliance with treatment plans. Complications from Underlying Conditions The most serious complications usually stem from the underlying disease, not from erythema nodosum itself. For example: Untreated TB can lead to lung damage and systemic infection Inflammatory bowel disease may require long-term immunosuppressive therapy Sarcoidosis, if active, can cause lung, eye, or nerve complications Therefore, it is critical to investigate and manage the root cause, not just the skin symptoms. Complications of Erythema Nodosum In South Africa In South Africa, complications may be more common due to late diagnosis, especially in rural areas. Limited access to tests, specialists, or appropriate medication can result in prolonged symptoms or untreated infections. Strengthening referral systems and community awareness can help reduce complications. The complications of erythema nodosum are usually preventable. Early identification, treating the cause, and managing symptoms properly can lead to full recovery with minimal long-term effects. [Next: Back to Overview →]

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Forearm with red circular lesions from erythema multiforme next to various medications

Erythema Multiforme

Erythema Multiforme, Health Conditions /

Erythema Multiforme Erythema multiforme is an acute skin condition that causes distinctive red or purple target-shaped lesions, often accompanied by itching or burning. This condition typically appears on the hands, arms, legs, and face, and in more severe cases, it can also affect the mouth, eyes, or genital areas. While the condition may look alarming, it is usually self-limiting and resolves within a few weeks. This disorder is often triggered by infections, particularly the herpes simplex virus (HSV). It can also result from certain medications, though this is less common. There are two main types: Erythema Multiforme Minor: which affects only the skin Major: which also involves mucous membranes and may cause systemic symptoms The condition is not contagious but can recur, especially in those with frequent herpes outbreaks. Episodes often follow a predictable pattern, starting with flu-like symptoms before the rash develops. Erythema Multiforme In South Africa, this condition may be under-recognised, especially in rural areas where skin disorders are frequently misdiagnosed. Quick identification and proper management can prevent complications and provide relief. Understanding this condition helps in early detection, accurate treatment, and avoiding unnecessary anxiety about its appearance. [Next: Causes of Erythema Multiforme →]

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3D rendering of herpes simplex virus, a common cause of erythema multiforme

Causes of Erythema Multiforme

Erythema Multiforme, Health Conditions /

Causes of Erythema Multiforme Infections usually cause erythema multiforme, and certain medications cause it less commonly. Erythema multiforme is considered a hypersensitivity reaction, meaning the immune system overreacts to a trigger, leading to inflammation and the characteristic rash. Infectious Triggers The majority of cases—particularly mild ones—are caused by infections. The most frequent culprits include: Herpes simplex virus (HSV) – The leading cause, especially in recurring cases. The rash often appears a few days after a cold sore or genital herpes flare-up. Mycoplasma pneumoniae – A respiratory infection that is more commonly linked to erythema multiforme major. Other viruses, such as Epstein-Barr virus, cytomegalovirus, and HIV, may occasionally trigger the condition. Fungal and bacterial infections – Though less common, can sometimes play a role. Medication Reactions In some people, drugs can trigger erythema multiforme. Common offenders include: Antibiotics, especially sulphonamides and penicillins Non-steroidal anti-inflammatory drugs (NSAIDs) Anticonvulsants, such as phenytoin and carbamazepine Barbiturates Drug-related cases are more often associated with erythema multiforme major and may take longer to resolve. If suspected, the medication should be stopped immediately under medical supervision. Other Triggers Rare causes include: Vaccinations Radiation therapy Underlying autoimmune conditions Causes of Erythema Multiforme In South Africa In South Africa, limited access to viral testing may make it difficult to confirm the exact cause of erythema multiforme. Many rural clinics may not associate skin eruptions with herpes or pneumonia. Education of frontline health workers is key to identifying patterns and treating the condition early. Prevention is possible in recurring cases by suppressing the triggering infection—often with antiviral medication in the case of HSV. Recognising the causes of erythema multiforme helps guide both treatment and prevention. Identifying the trigger allows for more targeted therapy and reduces the risk of recurrence. [Next: Symptoms of Erythema Multiforme →]

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Mild red spots on forearm showing early symptoms of erythema multiforme

Symptoms of Erythema Multiforme

Erythema Multiforme, Health Conditions /

Symptoms of Erythema Multiforme The symptoms of erythema multiforme often appear suddenly and include a range of skin and mucous membrane changes. Erythema multiforme typically starts with general discomfort or mild flu-like symptoms, followed by the appearance of distinctive skin lesions within 24 to 48 hours. Skin Symptoms Target lesions – The hallmark of the condition. These are round spots with three zones: a dark or blistered centre, a pale ring, and a bright red outer ring. Symmetrical rash – Lesions usually appear on both sides of the body, starting on the backs of hands and feet before spreading to arms, legs, and face. Itching or burning – Affected areas may feel irritated. New lesions – May continue to appear for up to a week. Crusting or peeling – In later stages, lesions may scab over or flake off. In mild cases, the rash is limited to the skin and resolves without scarring. Mucous Membrane Involvement In erythema multiforme major, mucous membranes may be affected, especially in the: Mouth – Painful ulcers or blisters that make eating or drinking difficult Eyes – Redness, discharge, or discomfort Genital area – Painful sores or inflammation Involvement of these areas can lead to severe discomfort and requires medical attention. In rare cases, conjunctivitis or corneal ulcers may develop, risking vision if untreated. Systemic Symptoms Before or during a flare-up, some people experience: Low-grade fever Fatigue Joint pain Headache General body aches These symptoms are more common in major cases and usually resolve as the rash improves. Symptoms of Erythema Multiforme In South Africa In South Africa, individuals with HIV may present with more frequent or severe episodes of erythema multiforme due to immune system dysregulation. Co-infections such as herpes simplex virus may also complicate the presentation. Clinics and hospitals should be prepared to treat both the skin condition and any underlying infection. Misidentifying erythema multiforme as another rash—such as measles, allergic reaction, or even Stevens-Johnson syndrome—can delay care. Identifying the symptoms of erythema multiforme early ensures faster treatment and avoids progression to more serious complications. [Next: Diagnosis of Erythema Multiforme→]

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Doctor examining red skin lesions on a patient's back for diagnosis of erythema multiforme

Diagnosis of Erythema Multiforme

Erythema Multiforme, Health Conditions /

Diagnosis of Erythema Multiforme The diagnosis of erythema multiforme is usually made based on clinical appearance, particularly the presence of characteristic target lesions. Since erythema multiforme can resemble other skin conditions, especially in its more severe forms, accurate diagnosis is important to guide treatment and rule out life-threatening conditions like Stevens-Johnson syndrome (SJS). Clinical Examination Doctors begin by examining: The shape and distribution of lesions Whether the mucous membranes are affected The symmetry of the rash Presence of blisters or crusting Any signs of systemic illness such as fever or malaise The presence of target lesions on the extremities, especially if symmetrical, strongly suggests erythema multiforme minor. If mouth, eye, or genital ulcers are involved, erythema multiforme major may be diagnosed. Patient History A thorough medical history helps identify potential triggers. Doctors ask about: Recent infections (especially herpes or chest infections) Medication use Vaccinations Previous similar skin reactions Chronic illnesses, especially autoimmune or immune-compromised conditions This helps pinpoint the most likely cause and decide whether treatment should include antivirals, antibiotics, or drug discontinuation. Laboratory Tests Blood tests may include: Complete blood count (CBC) – to check for infection or inflammation Liver and kidney function tests – if medication reaction is suspected HSV serology – in recurrent cases, to confirm herpes as the trigger Chest X-ray – if Mycoplasma pneumoniae is suspected These tests are not always necessary but may support the diagnosis in unclear or severe cases. Skin Biopsy In uncertain or severe cases, a skin biopsy may be done. A small sample of affected skin is examined under a microscope. This helps distinguish erythema multiforme from other serious skin conditions like: Stevens-Johnson syndrome Bullous pemphigoid Fixed drug eruptions Lupus erythematosus A biopsy is particularly important in patients with extensive blistering, systemic illness, or suspected drug reaction. Diagnosis of Erythema Multiforme In South Africa In South Africa, many diagnoses are made clinically, especially in rural areas where access to dermatologists or biopsy facilities is limited. Training primary care staff to recognise the condition and refer serious cases improves outcomes. The diagnosis of erythema multiforme relies on accurate pattern recognition and a good clinical history. Early identification allows for symptom control and prevention of recurrence. [Next: Treatment of Erythema Multiforme →]

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Person applying topical cream from a small tube as treatment for erythema multiforme

Treatment of Erythema Multiforme

Erythema Multiforme, Health Conditions /

Treatment of Erythema Multiforme The treatment of erythema multiforme focuses on symptom relief, removing the trigger, and preventing recurrence. In most cases, erythema multiforme is self-limiting and clears up without scarring within two to four weeks. Severe or recurring cases require closer medical attention. Mild Cases (Erythema Multiforme Minor) For patients with limited skin involvement and no mucous membrane damage: Antihistamines – Help reduce itching and discomfort Topical corticosteroids – Ease inflammation on affected skin Moisturisers – Protect the skin and promote healing Pain relief – Paracetamol or ibuprofen can manage fever or soreness Most cases resolve on their own once the trigger (usually a viral infection) passes. Moderate to Severe Cases If mucous membranes are involved (erythema multiforme major), or the rash is widespread, treatment may include: Oral corticosteroids, such as prednisone, to reduce inflammation Hospital admission, especially if eating or drinking is difficult IV fluids, to prevent dehydration Topical anaesthetic gels, for mouth or genital ulcers Eye drops, if the eyes are involved Severe oral involvement may require a soft diet, nutritional support, and careful oral hygiene. Treating the Underlying Cause Antiviral therapy, such as acyclovir or valacyclovir, is used in patients with HSV-triggered erythema multiforme Antibiotics, if a bacterial infection like Mycoplasma pneumoniae is present Drug discontinuation, if a new medication is the suspected cause In recurrent HSV-related cases, long-term suppressive antiviral therapy may be prescribed to prevent future flare-ups. Treatment of Erythema Multiforme In South Africa In South Africa, access to antiviral medications and steroids is generally available in urban centres but more limited in remote clinics. Public sector stockouts and diagnostic uncertainty may delay treatment. Patient education about triggers, especially viral infections, is essential for early self-reporting and care. The treatment of erythema multiforme is usually effective, particularly when started early. Preventing recurrence and managing discomfort are key goals. [Next: Complications of Erythema Multiforme →]

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