Erythema Nodosum

Overview

Erythema nodosum is a skin condition that causes tender, red bumps to form under the skin, most often on the front of both lower legs. It happens because the layer of fat just below the skin becomes inflamed. It is not a skin infection and is not contagious. It usually occurs as a reaction to something else going on in the body, such as an infection, a medicine, or another health condition.

Erythema nodosum is fairly uncommon. In the UK, it is thought to affect about 1 to 5 people in every 100,000 each year, though it can be more common in certain age and risk groups.

It can affect anyone, but it is most common in adults between 20 and 40 years old. Women are affected more often than men — about three to six times more frequently.

Symptoms

Common symptoms

• Tender, raised red lumps on the shins, usually on both legs.
• The lumps are often warm to touch and can be painful, especially when you stand or wear tight clothing.
• Over a few weeks, the lumps may soften and look like bruises, changing to purple, brown, or yellow before fading.
• Mild fever, tiredness, and joint pain can also happen.
• Some swelling of the legs or feet may occur.

Symptoms in children

• The same tender bumps can appear, often on the shins or occasionally on the forearms.
• It may develop after a sore throat, cold, or other infection.
• Children may also have a fever, feel tired, or complain of leg aches.

Symptoms in older adults

• The lumps may take longer to heal and can leave darker marks for a while.
• Underlying causes, such as certain medicines or other health conditions, are more likely to be found if a new case occurs in an older adult.

Causes

Main causes

• An infection, most commonly a sore throat caused by streptococcal bacteria (strep throat), but also other bacterial and viral infections
• A reaction to certain medicines, such as antibiotics, birth control pills, or sulfa medicines
• Pregnancy
• Inflammatory bowel disease, including Crohn’s disease or ulcerative colitis
• Sarcoidosis, a condition that can cause lumps or red patches on the skin and may also affect the lungs
• In about half of cases, no clear cause can be found

Risk factors

• Being a woman between the ages of 20 and 40
• Having a recent throat, chest, or skin infection
• Taking certain medicines, including some antibiotics, hormone pills, or seizure medicines
• Having an autoimmune or inflammatory condition such as sarcoidosis or inflammatory bowel disease
• Being pregnant

When to see a doctor

See a doctor urgently if:

• If the lumps are extremely painful, spreading quickly, or you feel very unwell with a high fever, seek same-day medical advice.
• If you have difficulty breathing, swelling of your face or throat, or confusion, call your local emergency number immediately.

Book a routine appointment if:

• If you notice tender red lumps on your legs or elsewhere, make a non-urgent appointment with a GP.
• If you also have joint pain, tiredness, or a fever that lasts for several days, tell your doctor.
• If you already have a condition like Crohn’s disease, ulcerative colitis, or sarcoidosis and notice these lumps, contact your specialist for advice.

Diagnosis

Your doctor will ask about your symptoms, medical history, recent infections, medicines, and any other health conditions. They will examine the bumps and feel them to check their texture and tenderness. If the appearance is typical, they may strongly suspect erythema nodosum. The next step is to look for a possible cause.

Tests that may be done

• Blood tests to check for signs of inflammation or infection
• A throat swab to test for strep throat
• A chest X-ray to look for changes that might suggest sarcoidosis
• A stool test to screen for inflammatory bowel disease
• A skin biopsy, where a small piece of the lump is removed and examined under a microscope — this is only needed if the diagnosis is uncertain

What to expect at your appointment

If the cause is not obvious, you will likely be referred for some tests. Results may take a week or two to come back. While you wait, your doctor can help you manage pain and swelling. Most cases settle on their own, and there is usually no reason to worry.

Treatment

There is no single cure for erythema nodosum, but treatment focuses on easing symptoms and addressing any underlying cause. Often the lumps clear up without any specific treatment once the trigger is removed or treated.

Self-care at home

• Rest and raise your legs whenever you can.
• Apply a cool, damp cloth to the lumps for 10 to 15 minutes several times a day.
• Wear loose, comfortable clothing and avoid tight socks, stockings, or anything that presses on the shins.
• Take over-the-counter pain relief if the pain is bothering you — ask your pharmacist which option is suitable.
• Do not pick, pop, or scratch the lumps.
• Keep the skin clean and dry.

Medical treatments

If symptoms are severe or last longer than a few weeks, your doctor may suggest a short course of prescription medicine to reduce inflammation and pain. These are used under medical supervision and for a limited time. If a bacterial infection is confirmed as the cause, you may be given medicine to fight the infection. If a medicine you are taking seems to be the trigger, your doctor will help you decide whether it is safe to stop or change it. Never stop a prescribed medicine without talking to your doctor first.

When is surgery considered?

Surgery is not used for erythema nodosum. The condition affects the fatty layer under the skin and is treated with self-care and medical management.

Living with this condition

During the first week or two, the bumps can be tender and may make it uncomfortable to stand for long. Try to rest with your legs raised when possible. Many people find the pain eases after a few days. You can continue normal daily activities if they feel comfortable, but avoid pushing through severe pain. Remember that the lumps changing colour and looking like bruises is part of normal healing.

Lifestyle tips

• Keep your legs elevated when sitting or lying down.
• Use a cool compress to soothe soreness.
• Wear loose trousers and soft, comfortable shoes.
• Avoid vigorous rubbing or scrubbing of the shins.
• Stay hydrated and eat regular, balanced meals.

Diet and exercise

There is no special diet for erythema nodosum, but eating a balanced diet supports your immune system and healing. Gentle exercise such as short walks or swimming is usually fine if it does not make the pain worse. Listen to your body and rest when you need to.

Mental health and emotional wellbeing

Having painful lumps on your legs can be worrying and may affect your confidence or mood. It is normal to feel anxious or frustrated. If these feelings last or affect your daily life, talk to your doctor or a counsellor. Reassure yourself that for most people, this is a temporary and treatable condition.

Prevention

Because erythema nodosum is usually a reaction to something else, it cannot always be prevented. But you can reduce your risk by treating infections early, practicing good hand hygiene, and being aware of how your body reacts to medicines.

Vaccines

There is no vaccine that prevents erythema nodosum directly. However, staying up to date with recommended vaccinations, such as flu and COVID-19 vaccines, may help prevent some infections that can trigger the condition.

Screening programmes

There is no routine screening for erythema nodosum. If you develop this condition, your doctor may suggest targeted tests to look for an underlying cause.

Complications

If left untreated

• The lumps may take longer to fade and can leave a temporary dark mark on the skin for a few months.
• If an underlying infection is not treated, it could spread or lead to other health problems.
• If an inflammatory condition such as sarcoidosis is found and not followed up, it may require treatment later on.

Long-term outlook

The outlook is very good. Most cases of erythema nodosum clear up completely within a few weeks to a couple of months. The lumps usually fade without permanent scarring. If it comes back, it often responds well to managing the cause. The most important step is to see a doctor, find the trigger, and get the right support.

Find support

International organisations

• DermNet ↗
• Patient.info ↗

Local organisations

• NHS ↗ · United Kingdom

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