Erythema Nodosum 

What Is Erythema Nodosum?

[dropcap]E[/dropcap]rythema nodosum is an inflammatory disorder involving the deep dermis layer of skin and subcutaneous fat septa that underlies the skin. It is characterized by eruptions of recurrent or persistent multiple painful, red nodules under the skin that leave a bruised appearance when healing and do not scar.

The lower legs are most affected, but sores can appear anywhere there is subcutaneous fat.

Q: How do the nodules develop in erythema nodosum?

A: The edges of nodules are poorly defined, and the nodules vary from 2-6 cm.

During the first week of eruption, nodules become tense, hard, and painful. During the second week, they change color from bright red to bluish or livid and may become soft, but do not ulcerate. As absorption progresses, the color gradually fades to a yellowish hue, resembling a bruise. This disappears in 1 or 2 weeks as the overlying skin sloughs off and is replaced.¹

The eruptive phase of erythema nodosum begins with flulike symptoms of fever and generalized aching followed by a painful rash within 1-2 days.  Aching legs and swelling ankles may occur and precede the eruption or appear during the eruptive phase and may persist for weeks.²

Currently, the most common cause of erythema nodosum is streptococcal infection in children and streptococcal infection and sarcoidosis in adults.³ Most sores in infection-induced erythema nodosum heal within 7 weeks, but active disease may last up to 18 weeks.

In contrast, 30% of idiopathic erythema nodosum cases may last more than 6 months. Idiopathic means that the cause is not known.

What Is Erythema Nodosum In Celiac Disease and/or Gluten Sensitivity?

• Erythema nodosum is an associated immune disorder of celiac disease.
• The association between celiac disease and other immune disorders may be due to the sharing of a common genetic background, such as HLA antigens.
• However, in a very large study, involving 909 patients with celiac disease, Ventura and his associates found that the development of immune disorders in celiac disease was clearly related to the duration of exposure to gluten.⁴

How Prevalent Is Erythema Nodosum In Celiac Disease and/or Gluten Sensitivity?

The actual prevalence of erythema nodosum is not established.

What Are The Symptoms Of Erythema Nodosum?

• Erythema nodosum is marked by recurrent or persistent multiple painful, red nodules under the skin that individually last about 2 weeks.⁵ Lesion borders are poorly defined, and lesions vary from 2-6 cm.
• During the first week of eruption, nodules become tense, hard, and painful.
• During the second week, they change color from bright red to bluish or livid and may become soft, but do not ulcerate.
• As absorption progresses, the color gradually fades to a yellowish hue, resembling a bruise. This disappears in 1 or 2 weeks as the overlying skin sloughs off and is replaced.
• Aching legs and swelling ankles may persist for weeks.¹

How Does Erythema Nodosum Develop In Celiac Disease and/or Gluten Sensitivity?

• Erythema nodosum results from increased intestinal permeability to ingested antigens from the gut and the hypersensitivity reactions or the formation of immune complexes involving gluten exposure in celiac disease.⁶

Does Erythema Nodosum Respond To Gluten-Free Diet?

Yes. Erythema nodosum responds to a strict gluten free diet.⁶

6 Steps To Improve Erythema Nodosum In Celiac Disease and/or Gluten Sensitivity:

• [dropcap]1[/dropcap]Remove the Trigger. Maintain a Strict, Nutritious Gluten Free Diet:

[box type=”shadow” ]Treatment. This condition responds to the complete elimination of gluten, which is the required treatment that improves both erythema nodosum and gut health.

• Gut health is the foundation to restore ALL health. Restored health will enable you to maintain a strict gluten free diet, just as other life tasks will be easier.
• A strict gluten free diet means removing 100% of wheat, barley, rye and oats from the diet.
• Cutting out bread and other obvious sources of gluten is not good enough for recovery. Even 1/8th teaspoon of flour or bread crumb is enough to sustain the inflammation that is damaging your small intestine, causing increased permeability (leaky gut) and allowing undigested gluten to enter your body where it can damage structures and function, and instigate immune inflammatory responses.

Correct Your Individual Nutritional Needs.

• Eat foods that can replenish missing nutrients. Find them under NUTRIENT DEFICIENCIES.
• Take nutritional supplements as needed. Find them under NUTRIENT DEFICIENCIES.

Recovery. You should begin to feel better within a week and notice more energy as inflammation subsides and the  absorbing cells that make up the surface lining of your small intestine are better able to function.

• Intestinal lining cells are replaced every 5 days. The healing process is like sunburn where the damaged surface layer of skin sloughs off and is replaced with new normal cells.
• Leaky gut normally resolves in two month after starting a gluten free diet and brings about a big improvement in health. Improvement in intestinal permeability precedes morphometric recovery (cell appearance and structure) of the small intestine in celiac disease.⁷
• The intestinal lining may take up to a year to heal.[/box]

• [dropcap]2[/dropcap] Reduce Inflammation. Foods to Eat and Foods Not to Eat:

Because gluten is inflammatory, eliminate OTHER inflammatory foods from your diet to reduce an additive effect to gluten. At the same time, try to eat foods that reduce inflammation (anti-inflammatory).

[box type=”shadow” ]Here Are Major Inflammatory Food Types That Reduce Healing:

• Damaging Foods. In susceptible persons, includes corn, dairy (cow), and soy. Lactose, the sugar in any animal milk disrupts intestinal permeability causing leaky gut.⁸
• Allergenic Foods. Includes foods that trigger the immune sytem to produce IgE antibodies. Allergy testing is the usual way to discover these offending foods.
• Shelf Stable Processed Foods. Includes any that contain additives and preservatives. Look for them on the nutrition label of the box or package. Additives and preservatives also disrupt intestinal permeability causing leaky gut.⁸
• Fats. Limit deep fried foods, trans-fats, saturated fats (animal fat/butter), and EXCESSIVE omega-6 fatty acid oils like corn oil. Rancid fats, sodium caprate (a medium chain fat), and sucrose monester fatty acid (a food grade surfactant) induce significant disruption of the intestinal barrier that causes leaky gut.⁸.
• Excessive Refined White Flours (bran layer removed). Includes products made from them such as cookies, bread, cakes, pies. Bran contains the vitamins and minerals that metabolize grains and slows the otherwise rapid entry of sugar from their digestion into the bloodstream. Also disrupt intestinal permeability causing leaky gut.⁸
• Refined Sugars.  Includes white sugar, corn fructose and high fructose corn syrup.
• Certain Spices. Includes paprika and cayenne pepper which disrupt intestinal permeability causing leaky gut.⁸
• Alcohol and Caffeine. Disrupt intestinal permeability causing leaky gut.⁸
• Cocoa and Black Tea increase blood sugar.
• Rosemary. Increases blood sugar levels and should not be used by persons with insulin resistance or diabetes. [/box]

[box type=”shadow” ]Here Are Important Anti-Inflammatory Food Types to Promote Health:

• Fruits. Contain ample amounts of vitamins, minerals and phytochemicals which are naturally occuring components in plants that detoxify toxins, carcinogens (reducing the risk by 50%) and mutagens.
• Non-Starchy Vegetables. Support intestinal integrity and provide ample amounts of vitamins, minerals and phytochemicals. Includes green leafy vegetables such as lettuce and kale, also onion, broccoli, garlic, and others.
• High Quality Complex Carbohydrates. Provide vitamins, minerals, and fiber while boosting serotonin levels to help you relax and feel calm. Includes whole grains, legumes, and root vegetables such as carrots, parsnips, sweet potatoes, turnips, red beets, and others.
• Antioxidants. Protect the body from inflammatory oxidant molecules that continually occur and help us handle stress and reduce irritability. Includes vitamin C-containing foods such as lemon, grapefruit, apricot, Brussels sprouts and strawberries, and others. Also, includes vitamin E-containing foods such as nuts, seeds, avocado, olive oil, and others. Cocoa is good, too.
• Omega-3 Fatty Acids. Balance opposing omega-6 fatty acids and bad fats. Fish sources includes tuna, salmon, cod, and others. Plants sources include flax, chia seeds, canola oil, and others.
• Probiotics. Supply normal microbes needed for colon health and health of the body such as these fermented foods: yogurt, kefir, and unpasteurized apple cider vinegar.
• Prebiotics/ High Fiber Foods.  Food with fiber keeps our population of colonic microbes healthy.
• Protective Herbs and Spices.  See below #6 below for examples.[/box]

• [dropcap]3[/dropcap] Information Sheet You Can Take to Your Doctor or Other Health Professional:

Click here.

• [dropcap]4[/dropcap] Manage Your Medications Safely:

[box type=”shadow” ]

Some medications contain gluten, which is a cause of erythema nodosum, and the word gluten may not be listed as such on the package. Ask your doctor or pharmacist about this possible source of gluten if you are taking drugs and have eruptions from erythema nodosum. Do not stop prescribed medications without supervision.

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• [dropcap]5[/dropcap]Nutritional Supplements To Help Correct Deficiencies:

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The type and quantity of nutritional supplements that may be needed depend on which nutrients are deficient.

• Multivitamin/mineral combination that provides 100% once a day is useful to improve overall nutrient levels. This is a safe dose, but always check with your doctor to avoid interactions with medications.

Storage Note: Store container tightly sealed, away from heat, moisture and direct light to avoid loss of potency. That is, in a safe kitchen cabinet – not in the bathroom or on the kitchen table.[/box]

• [dropcap]6[/dropcap]Manage Natural Remedies: 

[box type=”shadow” ]Hydration:

• Eight glasses of water are recommended per day unless there is a contraindication such as kidney or heart disease. The Institute of Medicine recommends approximately 2.7 liters (91 ounces) of total water, from all beverages and foods, each day for women and 3.7 liters (125 ounces) daily of total water for men.
• If you are thirsty, drink water. Add fresh, squeezed lemon to water. Lemon is anti-inflammatory, alkalizing and provides vitamin C.
• Hydration Test: Urine should be pale yellow. Fingertips should be plump, without pruning but this may not be reliable when fingers are swollen with edema. Lips should be plump, without puckering. The feeling of thirst can be unreliable.
• What is wrong with soda, coffee, tea, and alcohol? These drinks are dehydrating, increase acid, and deplete nutrients.[/box]

[box type=”shadow” ]Carminatives. The following  anti-inflammatory plant sources called carminitives help heal the digestive tract. They also tone the digestive muscles which improves peristalsis, thus aiding in the expulsion of gas from the stomach and intestine to relieve digestive colic and gastric discomfort.

Carminative Food Remedies:

• Raspberry.
• Carrot is also a cleansing digestive tonic.
• Grape is also bile stimulating and a cleansing remedy for sluggish digestion and laxative.
• Redbeets also stimulate and improve digestion and are easily digested.
• Cabbage also stimulates and improves digestion and is also a liver decongestant.
• Lettuce also stimulates and improves digestion and is also an alterative, meaning it improves the function of organs involved with the digestion and excretion of waste products to bring about a gradual change.
• Potatoes are antispasmodic (due to atropine like properties) and a liver remedy.

Carminative Herb Remedies:

• Sage is also a digestive, astringent, bile stimulant and energy tonic that heals the mucosa.  Drink as tea or use in cooking.
• Chamomile, lemon balm, and fennel, (as a tea) also help relieve nervous tension.
• Parsley also relieves indigestion.
• Rosemary as a tea and in cooking also is a nervous system tonic for stress and fatigue, bile stimulant, and can relieve headaches and indigestion. However, because it increases blood sugar levels, it should not be used by persons with insulin resistance or diabete.
• Thyme is also soothing remedy useful for stimulating digestion of rich, fatty foods.

Carminative Spice Remedies:

• Cloves are also antispasmodic.
• Nutmeg is also useful for indigestion.
• Ginger.[/box]

[box type=”shadow” ]Exercise Helps:

Exercise improves circulation and rids the body of toxins.

• Walking is aerobic exercise that reconditions the whole body to improve stamina. Read more about Exercise and Fitness.
• Weight training builds muscle. Read more about Exercise and Fitness.
• Stretching improves flexibilty. Read more about Exercise and Fitness.

Note: Exercise is important, but the amount and type of exercise undertaken depends on your health. Your first priority is to heal. [/box]

What Do Medical Research Studies Tell About Erythema Nodosum In Celiac Disease and/or Gluten Sensitivity?

CASE REPORT SUMMARIES

“Erythema nodosum in a child with celiac disease.” This case report describes a healthy, ten-year-old boy who presented with erythema nodosum in whom serological tests of autoimmunity and intestinal histological examination were compatible with celiac disease. The eruption resolved within 2 months following a gluten-free diet. Therefore, the possibility that erythema nodosum represents an extraintestinal manifestation of celiac disease should be kept in mind accordingly in cases where other common causes of this rash are ruled out.

It was postulated that the increased intestinal permeability to antigens may provoke the skin hypersensitivity reaction. Furthermore, it should be noticed that celiac disease may coexist with sarcoidosis which is a common cause of erythema nodosum. Actually, the coincidence of sarcoidosis, celiac disease, and erythema nodosum has been described but at that time erythema was attributed to sarcoidosis. Erythema nodosum may therefore not be such a rare manifestation of celiac disease. It may be on the contrary that this diagnosis is overlooked in children with erythema nodosum given that celiac disease can be atypical or latent without pronounced signs of malabsorption. Our patient belonged to this category as, with the exception of erythema nodosum, he had no other symptoms. It could be therefore classified to the silent form of celiac disease until the development of the eruption given that the intestine on the histological examination was damaged.

It should be noted that although the child had weight and height within the normal range (25th centile), before being on gluten-free diet, his height centile increased to the 50th after following a gluten-free diet. Therefore, his height at presentation was below his potential.⁹

“Erythema nodosum in association with celiac disease.” This case report of a 16-year-old girl with a 4 year history of chronic persistent erythema nodosum involving 2-3 cm painful, bright red to brown subcutaneous nodules on the extensor surfaces below both knees describes course and subsequent diagnosis of Celiac Disease, suggested by low serum iron levels. Within a month of starting a strict gluten free diet, the development of new nodules ceased and the old lesions resolved. After an approximately 3 month symptom-free period, she was unintentionally exposed to gluten. Two erythematous (red), infiltrated nodules appeared on her legs, which regressed spontaneously.¹⁰

“Erythema nodosum and coeliac disease.” This case report describes the diagnosis of celiac disease in a 17-year-old female patient with a 6-month history of recurrent erythema nodosum associated with episodes of diarrhea and megaloblastic anemia. The erythema subsided after treatment of the patient with a strict gluten-free diet.¹¹

Sources:

1. http://emedicine.medscape.com/article/1081633-clinical#a0217 [↩] [↩]
2. http://emedicine.medscape.com/article/1081633-clinical [↩]
3. http://emedicine.medscape.com/article/1081633-overview#a0199 [↩]
4. La Villa G, Pantaleo P, Tarquini R, Cirami L, Perfetto F, Mancuso F, Laffi G. Multiple immune disorders in unrecognized celiac disease: a case report. World J Gastroenterol. 2003;9(6):1377-1380, Available at: http://www.wjgnet.com/1007-9327/9/1377.asp. Accessed Jan 3, 2005. [↩]
5. Bartyik K, Varkonyi A, Kirschner A, Endreffy E, Turi S, Karg E. Erythema nodosum in association with celiac disease. Pediatric Dermatology. May-Jun 2004;21(3):227-30. [↩]
6. Bartyik K, Varkonyi A, Kirschner A, Endreffy E, Turi S, Karg E. Erythema nodosum in association with celiac disease. Pediatric Dermatology. May-Jun 2004;21(3):227-30. [↩] [↩]
7. Cummins AG, Thompson FM, Butler RN, et al. Improvement in intestinal permeability precedes morphometric recovery of the small intestine in coeliac disease. Clinical Science. Apr 2001;100(4):379-86. [↩]
8. Farhadi A, Banan A, Fields J, Keshavarzian A. Intestinal barrier: an interface between health and disease. Journal of Gastroenterology and Hepatology. 2003;18:479-91. [↩] [↩] [↩] [↩] [↩] [↩]
9. Fretzayas A, Moustaki M, Liapi O, Nicolaidou P. Erythema nodosum in a child with celiac disease. Case Rep Pediatr. 2011;2011:935153. doi: 10.1155/2011/935153. [↩]
10. Bartyik K, Varkonyi A, Kirschner A, Endreffy E, Turi S, Karg E. Erythema nodosum in association with celiac disease. Pediatric Dermatology. May-Jun 2004;21(3):227-30. [↩]
11. Durand JM, Lefevre P, Weiller C. Erythema nodosum and coeliac disease. British Journal of Dermatology. 1991;125(3):291–292. [↩]