Last reviewed: September 2018
Last updated: November  2017



History and exam

Key diagnostic factors

  • presence of risk factors
  • nodules on shins
  • uveitis, red eyes, retinal nodules, or candle-wax drippings
  • nodules on other skin areas
  • anaesthetic patches

Other diagnostic factors

  • joint pains
  • fever
  • diarrhoea, constipation, abdominal pain, haematochezia
  • enlarged spleen
  • miliary nodules on the retina

Risk factors

  • streptococcal infection
  • sarcoidosis
  • tuberculosis
  • coccidioidomycosis
  • histoplasmosis
  • blastomycosis
  • brucellosis
  • Behcet's disease
  • oral contraceptives
  • sulfonamides
  • iodides and anti-epileptic drugs
  • psittacosis
  • leprosy
  • inflammatory bowel disease

Diagnostic investigations

1st investigations to order

  • FBC
  • anti-streptolysin-O (ASO) titre
  • ESR
  • CXR
  • PPD skin testing
Full details

Investigations to consider

  • serum ACE level
  • granuloma lesion biopsy
  • coccidioidin skin test
  • histoplasmin skin test
  • lepromin skin test
  • blastomycosis serology
  • brucellosis serology
  • psittacosis serology
  • x-ray symptomatic joints
  • rheumatoid factor testing
  • Yersinia agglutination titre
  • Yersinia stool cultures
  • colonoscopy
  • serum IgD
  • deep punch biopsies including subcutaneous fat, or incisional biopsies
Full details

Treatment algorithm


Authors VIEW ALL

Daniela Kroshinsky

Director of Pediatric Dermatology

Department of Dermatology

Massachusetts General Hospital




DK declares that she has no competing interests.

Dr Daniela Kroshinsky would like to gratefully acknowledge Dr Om P. Sharma, a previous contributor to this monograph. Dr Kroshinsky would also like to thank Priyanka Vedak for her contribution to this monograph. OPS declares that he has no competing interests.

Peer reviewers VIEW ALL

Professor of Internal Medicine

Clinical Professor of Dermatopathology

Northeastern Ohio Universities College of Medicine


Associate Clinical Professor of Dermatology

Case Western Reserve University School of Medicine




RTB declares that he has no competing interests.

Consultant Dermatologist

King's College Hospital




EH declares that she has no competing interests.

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