Triggers, Clinical Manifestations, and Management of Pediatric Erythema Nodosum: A Systematic Review

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BACKGROUND/OBJECTIVES: Erythema nodosum (EN) is a septal panniculitis clinically characterized by bilateral erythematous tender subcutaneous nodules typically found on the shins. While recognized as the most common form of panniculitis, it is less frequently documented in children and infants. Currently, there are no established guidelines to diagnose and manage EN in children. This review aims to consolidate current data on triggers, clinical manifestations, and treatment options, and propose a management algorithm for pediatric erythema nodosum (PEN). METHODS: A systematic literature review of published PEN cases up to April 22, 2024, was conducted using PubMed, Embase, Cochrane, and MEDLINE databases. RESULTS: After full-text article review, 239 articles were included, representing 959 patients. The mean age was 10.2 years, ranging from 0.58 to 17.5 years. Infections were the main triggers: bacterial infections in 302 patients (31.5%), predominantly streptococcal; tuberculosis in 193 patients (20.1%); followed by idiopathic cases in 80 patients (8.3%); inflammatory bowel diseases (IBD) in 66 patients (6.9%); Behçet's disease in 61 patients (6.4%); leprosy in 38 patients (4.0%); drug related in 28 patients (2.9%); and to a lesser extent various other infectious agents, genetic diseases, vaccines, autoimmune and inflammatory conditions, and malignancies. Diagnosis relied mainly on clinical assessment, with only 111 patients (11.6%) undergoing skin biopsy. Most patients received supportive care, including NSAIDs, along with treatment of the underlying cause. CONCLUSIONS: Erythema nodosum affects children. It is mainly triggered by infections. The diagnosis is primarily clinical. Supportive care is the mainstay of treatment along with addressing the underlying cause.

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