Tag Archives: erythema nodosum

Frequency of Erythema Nodosum and Pyoderma Gangrenosum in 32,497 Pediatric Patients with Inflammatory Bowel Disease

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MY Yousif et al. JPGN 2024; 79:1009–1016. Open Access! The association between erythema nodosum and pyoderma gangrenosum and pediatric inflammatory bowel disease

Using the ImproveCareNow prospective registry, the authors analyzed a total of 285,913 visits from 32,497 patients aged ≤ 21 years.

Key findings:

  • The occurrence of erythema nodousm (EN) was 1.57% and the occurrence of pyoderma gangrenosum (PG) was 0.90%. Co-occurrence of EN and PG was reported in 0.30% patients.
  • Both EN and PG were associated (p < 0.0001) with worse intestinal disease, lower remission, higher inflammatory markers, and extraintestinal manifestations (EIMs) arthritis and uveitis. 
  • Limitations: “imperfect and incomplete data entry that may introduce bias. However, due to the extensive longitudinal data, we expect any bias to be minimal.”

My take: This study clarifies how common these dermatologic findings occur in pediatric patients with IBD. Prompt recognition of these disorders is important. Recently, our group cared for a 20 yo patient with inadequately-treated PG by multiple internal medicine physicians; this led to prolonged hospitalization.

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The Dancer by Auguste Renoir, National Gallery of Art

IBD Updates: Fatigue Trajectory, Risk of IBD with Derm Findings

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NZ Borren et al. Inflamm Bowel Dis 2021; 27: 1740-1746. Open Access: Longitudinal Trajectory of Fatigue in Patients With Inflammatory Bowel Disease: A Prospective Study

In this prospective study using the CCFA IBD Partners cohort, the authors examined fatigue symptoms with questionnaires (FACIT-F and MDI) at 3 timepoints over a 1 year period. There was likely a strong selection bias among participants (mean disease duration was 18 years) who chose to complete theses questionnaires. Key findings:

  • Persistent fatigue (at baseline and at 6 months) was the most common pattern, affecting two-thirds (65.8%) of patients
  • The strongest predictor of incident fatigue was sleep disturbance at baseline (odds ratio, 2.91.
  • Only 12.3% of those with fatigue at baseline had symptom resolution by 6 months. Resolution was more likely in patients with a diagnosis of ulcerative colitis, quiescent disease, and an absence of significant psychological comorbidity

My take: In those with fatigue, it is often persistent.

Related blog post: #MondayNightIBD and Fatigue

D King et al. Inflamm Bowel Dis 2021; 27: 1731-1739. The Risk of Later Diagnosis of Inflammatory Bowel Disease in Patients With Dermatological Disorders Associated With Inflammatory Bowel Disease

The authors retrospectively studied 7447 patients with dermatological conditions such as erythema nodosum (EN), pyoderma gangrenosum, Sweet’s syndrome, and aphthous stomatitis which can occur with inflammatory bowel disease (IBD) and are considered dermatological extraintestinal manifestations (D-EIMs).

Key findings:

  • 131 (1.8%) subsequent IBD diagnoses in patients with D-EIMs compared with 65 (0.2%) in those without D-EIMs
  • Median time to IBD diagnosis was 205 days (IQR, 44-661 days) in those with D-EIMs

My take: The absolute risk if IBD is low in patients with D-EIMs but still increased 6-fold. This would probably be a good population to screen for IBD with a biomarker (eg. calprotectin)

Related blog post: Review of Pyoderma Gangrenosum

J Shah et al. Inflamm Bowel Dis 2021; 27: 1832-1838. Ocular Manifestations of Inflammatory Bowel Disease Nice review: “ocular manifestations of IBD include keratopathy, episcleritis, scleritis, and uveitis and are among the most common extraintestinal manifestations.” Urgent referral to ophthalmology needed if deep eye pain that can awaken from sleep (?scleritis), if photosensitivity/blurry vision/headache (?anterior uveitis), or if floaters/decreased vision (?posterior uveitis)

Does Sun Exposure Lower the Risk of Crohn Disease?

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An intriguing recent study suggests that individuals who spend more time outside are less likely to develop Crohn disease (CD) (Inflamm Bowel Dis 2014; 20: 75-81).

In this prospective cohort study from France, 123 cases of inflammatory bowel disease (45 CD, 71 ulcerative colitis, and 7 indeterminant colitis)  developed among the 91,870 women in the study.  The study period had a mean followup of 13.1 years and followed women between 40 and 65 years. The authors estimated residential sun exposure by utilizing a database (derived from satellite collection) containing the mean daily ultraviolet radiation dose for each French county.

Key findings:

  • Higher levels of sun exposure were associated with a decreased risk of Crohn disease with a Hazard Ratio (HR) of 0.49.
  • Sun exposure did not affect the likelihood of developing UC (HR 1.21).
  • In women with information about dietary vitamin D intake, higher sun exposure had a HR of 0.29 for developing CD.  That being said, the authors note a low dietary vitamin D intake in their population.

Despite the large cohort, this study has a number of limitations. The absolute number of IBD patients can lead to a Type 1 error (false-positive conclusion).  In addition, the age of the study population and the lack of data regarding individual sun exposure limit the conclusions as well.  Besides these factors, there may be confounders such as changes in diet and soil exposure which are not accounted for.

At the same time, there have been other studies which have shown a latitude effect.  As with this study, those living in sunny areas had a lower incidence of CD.

Bottomline: This study suggests that additional sun exposure is associated with a lower risk of developing Crohn disease.  Whether this lower risk is directly through better vitamin D levels or simply an epiphenomenon is unclear.

Other recent unrelated studies:

Gut 2013; 62: 1122-30.  A randomized phase 1 study of etrolizumab (rhuMAb β-7) in moderate to severe ulcerative colitis.  Etrolizumab is an adhesion cell molecular blocker.

Inflamm Bowel Dis 2014; 20: 21-35.  Meta-analysis of 23 randomized controlled trials of probiotics for UC, Pouchitis, and CD.  Probiotics, in particular VSL#3, increased UC remission rates and helped maintain remission in patients with pouchitis.

Inflamm Bowel Dis 2014; 20: 213-27. Review article of cutaneous manifestations of inflammatory bowel disease.  Good pictures of multiple problems including metastatic Crohn disease, erythema nodosum, pyoderma gangrenosum, Sweet’s syndrome, aseptic abscess syndrome, and epidermolysis bullosa acquisita.

Inflamm Bowel Dis 2013; 19: 1753-63.  Review on hair loss associated with inflammatory bowel disease. Remember telogen effluvium?

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For those who read from the top to the very bottom, here’s a tangential question: Do you know what a “sun dog” is?   Sun dog – Wikipedia, the free encyclopedia