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| Fig. 37.7 Pancreatic panniculitis. Tender, erythematous, fluctuant nodules on the lower legs of a patient with acute pancreatitis. |
The pancreas is a 99% exocrine- (pancreatic digestive enzyme) and a 1% endocrine- (insulin, glucagon) producing organ. Acute pancreatitis caused by viral infection, drugs, alcohol, pancreatic cancer, or trauma leads to massive outpouring of digestive enzymes. Patients with pancreatitis are often extremely ill with fever, vomiting, eosinophilia, and severe abdominal pain. About 2% to 3% develop tender red fluctuant nodules on the lower legs (Fig. 37-7) associated with joint pain and swelling. Predominantly seen with chronic pancreatitis or pancreatic cancer, these nodules rupture and discharge a thick, oily liquid. Schmid’s triad, (panniculitis, polioarthritis, and eosinophilia) denotes a poor prognosis. The disease is caused by pancreatic lipase, phospholipase, trypsin, and amylase that migrate into tissue to cause the inflammation. It is felt that these pancreatic enzymes cause autodigestion of the fat in the subcutaneous tissue and periarticular fat pads. The histopathology is distinctive, demonstrating lobular liquefactive necrosis and ghostlike fat cells with neutrophils and other inflammatory cells. Administration of octreotide (inhibiting pancreatic enzyme manufacture) results in the cessation of symptoms. Steroids and nonsteroidal antiinflammatory drugs (NSAIDs) do not effectively treat skin nodules.
Garcia-Romero D, Vanaclocha F: Pancreatic panniculitis,
Dermatol Clin 26(4): 465–470, 2008.
