Inflammatory Conditions Affecting the Subcutis: Treatment and Management

Erythema Nodosum

The American Gastroenterological Association recommends NSAIDs as the cornerstone of treatment for erythema nodosum, with systemic corticosteroids reserved for severe cases after excluding infectious causes, and immunomodulators used for frequent relapses or IBD-associated disease 1
Erythema nodosum is characterized by raised, tender, red or violet subcutaneous nodules measuring 1-5 cm in diameter, typically bilateral and symmetrical on the anterior tibial areas, with systemic symptoms including fever, malaise, and extreme fatigue 2, 1
Inflammatory bowel disease (ulcerative colitis and Crohn's disease) occurs in 4.2-7.5% of IBD patients, and is a known cause of erythema nodosum 2, 1
The European Crohn’s and Colitis Organisation recommends treating the underlying bowel inflammation with systemic steroids for IBD-associated erythema nodosum 2
Azathioprine and TNF-alpha inhibitors (infliximab or adalimumab) may be used for frequent relapses or refractory disease 2, 1

The American Thoracic Society recommends augmentation therapy with purified human AAT or fresh frozen plasma as the rational and effective treatment for AAT deficiency-associated panniculitis, with dapsone as adjunctive therapy 3
AAT deficiency-associated panniculitis is characterized by painful, hot, red, tender nodules on thighs and/or buttocks in young adults, with subsequent ulcerations and drainage of clear, yellow, oily, sterile fluid 3
Approximately one-third of cases are precipitated by trauma, and the condition can be lethal, particularly with coexisting cirrhosis or emphysema 3

The European Crohn’s and Colitis Organisation recommends infliximab as a preferred treatment option for pyoderma gangrenosum in ulcerative colitis patients, with a demonstrated 69% response rate and 31% remission rate at 6 weeks 2
Pyoderma gangrenosum is characterized by initially single or multiple erythematous papules or pustules, progressing to deep excavating ulcerations with sterile purulent material, often preceded by trauma at the site (pathergy phenomenon) 2
Systemic corticosteroids are traditionally used as first-line treatment, with intravenous ciclosporin and oral or intravenous tacrolimus as second-line options for refractory cases 2

The European Crohn’s and Colitis Organisation recommends systemic corticosteroids as an effective treatment for Sweet's syndrome associated with ulcerative colitis 2
Sweet's syndrome is characterized by tender, red inflammatory nodules or papules affecting upper limbs, face, or neck, with a strong predilection for women and patients with colonic involvement and other extraintestinal manifestations 2

The European Crohn’s and Colitis Organisation recognizes anti-TNF treatment as a cause of paradoxical skin inflammation, which is usually reversible upon drug cessation 2
Anti-TNF-induced skin inflammation is a class-drug effect affecting all TNF-alpha inhibitors, and referral to a dermatologist is recommended when diagnosis is uncertain 2