treatment of suture granuloma
Generalized granuloma annulare tends to occur in adults aged 30 and older. . Electron microscopic documentation of late changes in permanent fillers and clinical management of granulomas in affected patients. alcian blue pH 2.7 or colloidal iron), Polymethylmethacrylate (PMMA) with bovine collagen (Artefill/Artecoll/Arteplast), Uniform round nonbirefringent bodies in cystic spaces, Poly(hydroxyl)ethylmethacrylate with hyaluronic acid (DermaLive/DermaDeep), Irregular polygonal, pink, nonbirefringent particles that resemble broken glass in cystic spaces, Irregular fusiform, oval and spiky birefringent particles in cystic spaces that resemble suture material, Calcium hydroxylapatite (Radiance/Radiesse), Polyvinylpyrrolidone-silicone suspension (Bioplastique), Irregular cystic spaces containing translucent jagged popcorn nonbirefringent particles, Papule with a central black dotBirefringent material with polarized lightStain with PAS, In setting of pseudofolliculitis barbae, acne keloidalis nuchae, ruptured epidermoid cysts, ingrown nails, and pilonidal sinusesVariably birefringent keratin flakes or hair shaftsStain with acid-fast stains, Immunohistochemical staining with anti-keratin antibodies, Birefringent material with polarized lightStain with PAS, Nodules within a surgical scar or an inflamed wound that can develop a fistulaBirefringent fibers with polarized light, Nodules at joints or ear helicesAmorphous pink material in formalin-fixed tissue, Alcohol-fixed tissue preserves the birefringent crystals that stain with silver stains, Pulsed carbon dioxide laser (Q-switched laser is contraindicated for tattoos with granulomatous reactions), Minocycline or doxycycline 100mg once to twice daily with or without celecoxib 200mg twice dailyIsotretinoin 20mg daily for 6 months, CorticosteroidsTacrolimus 0.1% twice daily, Corticosteroids up to 60mg/dayCyclosporine up to 5mg/kg/day, Observation (usually resolves as material degrades), Corticosteroids 2.5-10mg/mLHyaluronidase 150U/mL (0.5mL combined with 1.5mL of 1% lidocaine with epinephrine)not into inflamed lesions, Corticosteroids up to 60mg/dayMinocycline 250mg twice daily for one week, Corticosteroids 2.5-10mg/mL in anesthetic solution5-fluorouracil (0.9mL of 5-FU 50mg/mL mixed with 0.1mL of triamcinolone 10mg/mL) given in 0.05mL aliquots every 2-4 weeks, Corticosteroids 2.5-10mg/mL5-fluorouracil (250mg/mL 5-FU mixed with triamcinolone 10mg/mL and 1mL of 1% lidocaine) injected with 27-G needle every 2-4 weeks, Allopurinol 200-600mg daily for average of one year, CorticosteroidsIbuprofen 1800-2400mg dailyAllopurinol 400mg dailyMinocycline 200mg dailyHydroxychloroquine 6mg/kg daily, Avoid lip area for injections (increased risk of nodules), Wood splinter/cactus spine/arthropod parts, For pseudofolliculitis barbae (PFB) and acne keloidalis nuchae (AKN), retinoids, glycolic acid, and/or clindamycin, For PFB, AKN, and pilonidal sinus, laser hair removal with long-pulsed lasers (alexandrite, 810nm diode or Nd:YAG), For PFB and AKN, avoid shaving or, if clean-shaven look desired, shave everyday in the direction of hair growth and lift any ingrowing hairs prior to shaving, Observation for spontaneous extrusion of suture. The double-ligature is a preferable alternative to multiple topical applications of silver nitrate for the treatment of . Since many of the treatment recommendations for foreign body granulomas are anecdotal or based on small case series, the exact time frame to expect results, and switch therapy if a patient is unresponsive, is quite subjective. Abnormal lumps and bumps can be concerning, especially when they develop on the incision line after skin cancer surgery. According to the most recent guidelines for the stoma care nurses the first line of treatment would be using a silver nitrate pencil. Autoimmune diseases, or health conditions linked to the immune system, are the most common cause of internal granulomas. In these cases, individuals should be referred to the appropriate caregivers for psychological counseling. DOI: 10.1016/j.bjps.2011.07.033. Certain medications can help clear your skin by reducing inflammation. A suture granuloma essentially is a foreign body reaction to suture remaining in the tissue after surgery. A suture granuloma resistant to antibiotics is treated with surgical excision, accomplished internally. Too many sutures and knots with a larger caliber of suture may increase the risk of suture reactivity, which may cause postoperative complications, such as abscess, granuloma or fistula at the . no financial relationships to ineligible companies to disclose. The differential diagnosis, both clinically and histologically, includes fungal and mycobacterial infections, leishmaniasis, and sarcoidosis. Learn more here. Scar revision of the abdominal wall. The cause of granuloma annulare is unknown and it is found in patients of all ages. If you wish to read unlimited content, please log in or register below. 12319 North Mopac Expressway | Bldg. Treating Umbilical Granulomas In most cases, treating granulomas is simple. Primary prevention: The risk of a foreign body granuloma may be reduced by avoiding gut sutures and by proper draping to keep lashes out of the surgical field. However, not all of these growths are worrisome. Read More Created for people with ongoing healthcare needs but benefits everyone. This series is coordinated by John E. Delzell Jr., MD, MSPH, associate medical editor. It causes inflammation in the gastrointestinal tract, leading to a variety of symptoms, including: Some people with Crohns disease will develop granulomas in their gut. Physical examination revealed a midline vertical scar with a 5.5-cm, dark brown, firm, fixed nodule (see accompanying figure). The condition tends to be seen in otherwise healthy people. Hypersensitivity reactions to bovine collagenresult in induration and erythema in the area where the collagen has been injected. Is the ketogenic diet right for autoimmune conditions? You can learn more about how we ensure our content is accurate and current by reading our. Generally, granulomas are treated with medications, like anti-TNF therapy, that decrease inflammation. Essentially, the lump is an inflammation that is created by extravasated sperm. 2012;33(2):E5. ), (The author explains the biology of facial fillers, including the biology of phagocytosis and granulomatous inflammation. Note that this may not provide an exact translation in all languages, Home Suture material may even extrude on its own with little or no manual assistance; intralesional corticosteroids can also be tried for suture granulomas prior to more invasive surgical procedures. Sometimes it is associated with diabetes or thyroid disease. Additionally, on occasion patients will inject themselves with a foreign body for secondary gain or as part of a psychiatric illness. Keloids are common, benign neoplasms consisting of increased fibroblasts and collagen that may occur after a trauma or surgical procedure. SALEM NH. For a granulomatous reaction to hyaluronic acid, intralesional hyaluronidase or extrusion using a #11 blade could be considered before corticosteroids, although caution should be taken with injecting hyaluronidase into actively inflamed areas. Small Skin Incision Method It is rare, but, Sarcoidosis is a chronic inflammatory condition which causes persistent granulomas. Patients with certain dermatologic conditions, such as pseudofolliculitis barbae, acne keloidalis nuchae, ingrown nails, epidermoid cysts, and pilonidal sinus, are at increased risk of keratin granulomas. In most cases, skin granulomas will go away on their own without treatment. In group 1, 13 patients developed tissue reaction, whereas in other groups, this re - action was not seen (Fig. It may be confused with a tumor or a recurrent tumor after surgery and should be considered in the differential in the correct setting. 1984. pp. 35. Granulomatosis with polyangiitis. Foreign body reaction to external agents - tattoos. Granuloma annulare is a benign skin condition characterized by small, raised bumps that form a ring with a normal or sunken center. {"url":"/signup-modal-props.json?lang=us"}, Morgan M, Bell D, El-Feky M, et al. Pathology of granulomatous diseases: foreign body granulomas. Picosecond lasers have also been used. biopsy specimens showed granulomatous cutaneous involvement. These lesions consist of granulation tissue that develops as a reaction of some types of immune cells to a foreign body. At the time the article was last revised Daniel J Bell had A granuloma is a histological term for a collection of histiocytes or epithelioid histiocytes accompanied by a range of multinucleated giant cells (masses of macrophages) and other inflammatory cells [1]. Check for errors and try again. This material may not be published, broadcast, rewritten or redistributed in any form without prior authorization. Talc (hydrous magnesium silicate) is found in many antibiotic and dusting powders and may cause granulomas if these powders are applied to open wounds. Perforating granuloma annulare can leave a scar. ), (The various lasers available for tattoo removal, as well as the recommended procedure protocol, are reviewed. Introduction. If suture granuloma mimicking local recurrence is a differential diagnosis, it would be important to consider to avoid unnecessary extended resection. 15. ), (In this study of 425 patients with systemic sarcoidosis, 65 patients had cutaneous lesions that demonstrated granulomatous inflammation on biopsy. Latest News Your top articles for Saturday, Continuing Medical Education (CME/CE) Courses. It is possible that a lump or granuloma may form as a reaction to suture material used in eyelid surgery. The use of laser surgical instrumentation is fast becoming a useful tool to assist in treatment of lick granulomas in dogs. Sorry, no locations are in this area. With the increasing number of hysterectomies and cesarean deliveries, the incidence of endometriomas is likely to increase.9 Endometriomas may present as early as three months after surgery and as late as 10 years after surgery, with the median time being two to three years postsurgery.35 Wide local excision is the preferred treatment.5 Medical therapies such as oral contraceptives, stanozolol (no longer available in the United States), or gonadotropin-releasing hormone analogues may lead to temporary benefits, but are associated with a high recurrence rate.7,10. Granuloma annulare can affect any part of the body. 427-30. Sarcoidosis is an autoimmune condition. A foreign body granuloma forms in response to the introduction of exogenous material to the skin, or in response to modified endogenous material that the immune system identifies as foreign [3]. A nodule may form at the site of intralesional corticosteroid injection, due to incomplete absorption or unusual dispersion of the injected material. 2001. pp. Microbiol. Registration is free. The laser instrument ablates (removes) the tissue by vaporizing the surface layers. Dont miss out on todays top content on Dermatology Advisor. Conservative treatment of ingrown nails includes placing gauze between the lateral nail plate and lateral nail fold, and also bracing the nail. Doctors call this localized granuloma annulare. mild irritation of the skin around the navel. 6, Bee Cave, TX 78738 - (512) 366-8568, 701 Metairie Road, Metairie, LA 70005 - (504) 836-2050, 3434 Prytania St., New Orleans, Louisiana 70115 - (504) 897-5899, 111 Veterans Boulevard, Metairie, LA 70005 - (504) 838-8225, 1900 Saint James Place, Houston, TX 77056 - (713) 850-0240, 12319 North Mopac Expressway, Austin, Texas 78758 - (512) 837-3376, 3705 Medical Parkway, Austin, Texas 78705 - (512) 454-3781, 13830 Sawyer Ranch Road, Dripping Springs, TX 78620 - (512) 829-0009, 1601 E. Pflugerville Parkway, Pflugerville, Texas 78660 - (512) 252-3700, 5145 North FM 620 Rd, Austin, Texas 78732 - (512) 266-0007, Dripping Springs Clinical Research Trials, eliminate the foreign material through the skins surface. Most plastic surgeons put specific sutures in certain tissues for a reason. For this reason, any patient who has had even one incident should discuss this with their physician and surgeon before any subsequent medical procedure. If systemic sarcoidosis is suspected in a patient presenting with a foreign body granuloma, an appropriate workup is recommended. ), Hirsch, BC, Johnson, WC. It has been proposed that sarcoidosis occurs when a genetically susceptible person is exposed to an environmental antigen. Fluorouracil injections have also been used. There are different types of granulomas. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. When this is the case, doctors will usually recommend treating the underlying condition. Some foreign body reactions (ie, those due to keratin, suture, tattoo ink, paraffin, bovine collagen, and hyaluronic acid, among others) have a distinctive pathology. What is the latest research on the form of cancer Jimmy Carter has? If systemic sarcoidosis is suspected, an appropriate workup is recommended. Clinical photographs taken at each appointment can also be helpful in determining if the patient is responding to treatment. Infect. Quiz yourself on Granulomas 9 Questions available Tuberculosis: Pathology review vol. Increased Granuloma Formation from Absorbable Sutures. Last medically reviewed on June 29, 2021, Eosinophilic granuloma is a rare condition where a benign growth can appear on the bone. "Suture granulomas can resolve on their own, and simply monitoring it or using an anti-inflammatory agent may be all that's needed," says Dr. Mamelak, our dual board-certified dermatologist. Granulomas develop in the blood vessels, making it difficult for blood to reach vital organs. If it is determined you have a suture granuloma, there are a number of treatment options available. They typically present in the months following a trauma or procedure, as the wound heals. 1991. pp. Journal of plastic, reconstructive & aesthetic surgery. Pyogenic granuloma (PG) is a common benign vascular proliferation. The granuloma can look red and swollen in some cases. Rheumatology 54 years experience. The first treatment you try may not work. We blend experience, education, technology, compassion, and exceptional skills to provide you with an unparalleled quality of care. Granulomas are small clumps of immune cells. Another type of light therapy, laser treatments, can also be helpful. But there are some things that can make it more likely. (In this comprehensive review, the authors discuss the most commonly used fillers, the most common adverse reactions, as well as the characteristic histopathologic findings that allow the identification of the injected filler agent. To be considered for publication, submissions must meet these guidelines. DermNet provides Google Translate, a free machine translation service. vol. That means it happens because of a fault in the immune system. Foreign body granulomas due to cosmetic fillers may be treated with antibiotics, oral steroids, and. Granulomas may appear as persistent subcutaneous nodules some months after injection. These epithelioid histiocytes coalesce and form the characteristic foreign body giant cells, which have numerous nuclei irregularly distributed in the cytoplasm (Figure 2). vol. Debridement of skin granulomas of the abdominal wall. 25. Prescription-strength products may help clear the skin faster. According to the Foundation for Sarcoidosis Research, having too many granulomas can interfere with the structure and function of organs. Granulomas can also form around a permanently placed medical device. See permissionsforcopyrightquestions and/or permission requests. The treatment of choice is resection of the retained suture and surrounding inflammatory tissue. Become a Gold Supporter and see no third-party ads. Cardiovascular health: Insomnia linked to greater risk of heart attack. ), Close more info about Foreign Body Granuloma (Foreign Body Reaction). (2016). 157-78. A Verified Doctor answered. vol. Case report: A 24-year-old female patient presented with pain, swelling, and drainage from a left lower quadrant abdominal wound that had been present since undergoing a laparoscopic appendectomy 1 year prior. 426-34. Underlying health conditions can also cause granulomas. The development of foreign body granulomas is thought to be under the control of both the humoral and cell-mediated immune system pathways and most likely represents a type IV hypersensitivity reaction to a foreign antigen. Suture granulomas can present in the neck after thyroidectomy, mimicking recurrence 4. Dermatol Clin. Some people may experience lumps on more than one part of the body at a time. Objective: Suture granulomas are localised inflammatory reactions that develop at the site of retained suture material. ), (In this review, the authors discuss the distinguishing clinical and histopathologic findings in various epithelioid granulomas, including zirconium and beryllium granuloma. A similar reactioncan affect people handling sea urchins. vol. Suture removal is the only treatment that can resolve suture-related complications of buried-suture double-eyelid blepharoplasty. Silver nitrate is a topical treatment applied directly onto the skin using a 'matchstick' applicator. The answer is A: cutaneous endometrioma. DermNet does not provide an online consultation service.If you have any concerns with your skin or its treatment, see a dermatologist for advice. These granulomas are most commonly associated with embedded suture material, or material inadvertently left under the skin following the removal of surgical sutures or staples, explains Dr. Adam Mamelak, board certified Dermatologist and Mohs Micrographic Surgeon at Sanova Dermatology. The lesion became more painful and bled during menses. 1-34. Silicone granulomas can form in the dermis when trauma causes the capsule around asilicone implantto rupture. Learn more about causes, symptoms, and treatment for this, Granulomatosis with polyangiitis (GPA) is an inflammation of the blood vessels that can affect the lungs, kidneys, and other organs. Copyright 2023 American Academy of Family Physicians. Takeshita N, Tohma T, Miyauchi H et-al. Other methods of removal depend on the cause. If you have any concerns with your skin or its treatment, see a dermatologist for advice. The most common presentation is a reddish-brown nodule in a previous scar. Treatment also consists of treating the underlying cause. Background Granuloma annulare (GA) is a benign, usually self-limiting, dermatosis, that typically presents as asymptomatic, flesh-colored or erythematous papules, frequently arranged in an annular or arciform pattern on the distal extremities. It tends to affect children more than adults, and it does not hurt. Background Schloffer's tumors are named after Hermann Schloffer (1868-1937), an Austrian surgeon who unusually was both a pre-eminent neurosurgeon and abdominal surgeon. Such treatments include: Scraping and burning (curettage and cauterization). Surgical removal may be undertaken if other treatment options fail. Typically, they are diagnosed by palpation because they are more prominent with increased abdominal pressure and may be reduced with external pressure. The biology of facial fillers. 2004-2023 Healthline Media UK Ltd, Brighton, UK, a Red Ventures Company. Suture granulomas can present in the neck after thyroidectomy, mimicking recurrence 4. Kikuchi M, Nakamoto Y, Shinohara S et-al. - Conference Coverage Anyone with a granuloma that does not get better on its own, or that keeps coming back, should speak with a doctor. Specialized training programs managed by the American College of Mohs Surgeons and others in the United States . Granulomatosis with polyangiitis is a rare disease. Register for free and gain unlimited access to: - Clinical Updates, with personalized daily picks for you 409-17. Removal of foreign bodies, x7 of the abdominal wall. They may appear as smooth, red-purple, sessile or pedunculated lesions most commonly on skin or subcutaneous tissue. How Viagra became a new 'tool' for young men, Ankylosing Spondylitis Pain: Fact or Fiction, tends to affect children more than adults, https://radiopaedia.org/articles/granuloma?lang=us, https://www.stopsarcoidosis.org/what-is-sarcoidosis/causes-risk-factors/, https://www.crohnscolitisfoundation.org/what-is-crohns-disease/causes, https://rarediseases.org/rare-diseases/granuloma-annulare/, https://medlineplus.gov/granulomatosiswithpolyangiitis.html, https://dermnetnz.org/topics/granuloma-annulare/, https://www.crohnscolitisfoundation.org/what-is-crohns-disease/overview, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5192066/, https://www.stopsarcoidosis.org/what-is-sarcoidosis/, https://www.ncbi.nlm.nih.gov/books/NBK554586/. Suture granulomas develop from your immune system trying to create a barrier between the foreign material and your natural body tissues. Progesterone can come from residual ovarian tissue or from medical hormone treatments. Dermatologic clinics. Of course, with any sudden, unexplained skin growth, you should have it evaluated by your dermatologist as soon as possible. This looks like a little lump at the site of the damage. Skin-nontumor: Foreign body reaction PathologyOutlines.com, Books about skin diseasesBooks about the skin Ultrasound Med Biol. This is a granulomatous condition of the skin caused or worsened by a dog compulsively licking a specific spot on their body until a granuloma develops; Juvenile cellulitis (puppy strangles) Cytokines help to activate fibroblasts, which will make collagen, trigger endothelialization, and help with the formation of new blood vessels, a . 3. In addition, cisplatin, which was concurrently administered with radiation in our case, could have influenced the development of the suture granuloma. arrow-right-small-blue Lichenoid or eczematous plaques may also occur. Is it a sarcoidal foreign-body granuloma or a cutaneous sarcoidosis on a permanent eyebrow make-up?. ESCA electron spectroscopy for chemical analysis. The treatment options range from only observation, simple excision of the tissue and the suture with a No.10 scalpel blade, electrocauterisation or application of hot compress 3-4 times a day for skin . Substances that cause foreign body granulomas include: Foreign body granulomas most commonly appear as red or red-brown papules, nodules or plaques, which may or may not ulcerate [2,3]. Essentially, the granulomatous response is an attempt by the body to wall off the foreign material. It commonly occurs several years after different types of surgeries. Some cases of granuloma annulare can be stubborn. Essential features. Park TH, Seo SW, Kim JK, Chang CH. Yonsei Med. Who is at Risk for Developing this Disease? Treatment options include: Medications. 2011 Sep 1;64(9):1216-20. The differential diagnoses include: Foreign body granulomas can be excised. Diagnosis will depend on where the granulomas are. Suture granulomas, for instance, can appear on or near the area where stitches were placed during a past surgery. Based on the patient's history and physical examination, which of the following is the most likely diagnosis? Maybe: There are numerous diseases which can form granulomas. To diagnose internal granulomas, doctors will need to understand the underlying cause of the problem. Close follow-up will allow the clinician to appreciate even small interval changes in the patients condition. Special stains, such as periodic acid-Schiff (PAS), Grocotts methenamine silver (GMS), acid-fast, and Giemsa, as well as tissue cultures should be performed if clinically indicated. Suture granulomas may reoccur. A biopsy of the lesion confirms the diagnosis. Dr. Zahid Niazi answered Cosmetic Surgery 40 years experience Likely yes: Depends - anytime the suture is exposed and within an infected granuloma, it is best to remove it as the half life of the current day dissolvable sutu. This content is owned by the AAFP. The only ligature i could find was under skin tags 11200. Patients should be referred for elective surgical repair. Linear granuloma is very rare. ), Marcoval, J, Mana, J, Moreno, A, Gallego, I, Fortuno, Y, Peyri, J. Eosinophilic granuloma: Everything you need to know, Granulomatosis with polyangiitis (GPA): What you need to know, irritating substances, such as silica or some tattoo inks, being between the ages of 20 and 40 years, being of European, particularly Scandinavian, descent, ongoing cold symptoms, such as a runny nose, ask a series of questions about the persons symptoms, carry out an imaging test, such as an X-ray or, take a tissue sample by performing a needle biopsy. 2016 Jan 2;18(1):502. Lick Granuloma Bandage. Three surgical methods for suture removal were performed under local anesthesia. This skin condition is simply a grouping of immune cells, most often caused by the sutures becoming embedded in the skin, or some of the material being left under the skin when the suture was removed. You will need to go back to the hospital for around 4 weeks, 1 day each week to have the treatment repeated. - And More, (In this comprehensive review, the authors discuss the most commonly used fillers, the most common adverse reactions, as well as the characteristic histopathologic findings that allow the identification of the injected filler agent. 1681-8. DermNet does not provide an online consultation service. Postoperative surveillance following radical colectomy is vital to the successful treatment of colorectal cancers, and various imaging modalities are used for this purpose [].However, surgery-related foreign body granulomas can mimic tumors on imaging studies and can therefore mislead clinicians into applying unnecessary interventions [2,3,4,5].In this report, we describe a rare case of a . A high index of clinical suspicion of this uncommon surgical complication and . The signs and symptoms of granuloma annulare can vary, depending on the type: Localized. Granulomas are not cancerous. Bolognia JL, Jorizzo JL, Rapini RP (eds). 0. Suture granuloma is a rare surgery-related complication in the postoperative surveillance of patients with colorectal cancer. (In this review, the author discusses the various modalities available for identification of cutaneous foreign bodies. 2001;27 (3): 343-50. The most effective treatment for granulomas is the topical application of silver nitrate. Rettenbacher T, Macheiner P, Hollerweger A et-al. Thanks for visiting Dermatology Advisor. arrow-right-small-blue 73-85. Chung YE, Kim EK, Kim MJ et-al. Falagas ME, Kasiakou SK. Subcutaneous granuloma annulare is often just one lump underneath the skin. They can develop anywhere on the body, including the skin, lungs, and other organs. At the time the article was created Matt A. Morgan had no recorded disclosures. Doctors do not know what causes sarcoidosis. Laser hair removal can be attempted to treat pilonidal sinuses and hair granulomas in barbers, with excision as definitive treatment of recurrent or recalcitrant lesions. 3. Talc granulomas are erythematous papules or nodules that can take years to appear. This can happen on the skin or inside the body. It may become a palpable and tender mass, mimicking tumor or recurrent tumor. Clinical conference: management of rare events following dermal fillersfocal necrosis and angry red bumps. Foreign bodies are most commonly introduced into the body through voluntary means, such as tattoos and cosmetic fillers. When this is the case, doctors will focus on treating the underlying cause of the lumps. October 2017. An important clue is that these lesions occur in an arrangement localized to the area of inoculation (Figure 1); however, as is the case with silicone, the foreign material may migrate, leading to granulomas at sites distant from the area of implantation. What the nurse will do is just press the pencil down on the granuloma causing it to reduce in size. A similar process may also occur in certain situations with mesh repairs 5. The Licensed Content is the property of and copyrighted by DSM. Topical treatment of pyogenic granuloma Imiquimod cream 5% Pyogenic granuloma can occur after any incision or trauma to the conjunctiva. Granulomas occur because of an injury to the back of the larynx (voice box). It is generally a tender, erythematous nodule that occurs several days to weeks.
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