Erythema annulare centrifugum: results of a clinicopathologic study of 73 patients

Evaluation of Clinicopathological Features and Associated Conditions in Erythema Annulare Centrifugum: A Retrospective Observational Analysis of 63 Patients

INTRODUCTION

Erythema annulare centrifugum (EAC) is a rare reactive disease that typically presents as annular or polycyclic erythematous lesions. There are few studies about EAC in the literature; therefore, data on the pathogenesis of the disease are limited.

OBJECTIVES

We aimed to examine the demographic, clinical, pathological characteristics and associated conditions of the patients with EAC.

METHODS

We analyzed records of the patients with EAC who admitted to our clinic in the last four years retrospectively.

RESULTS

A total of 63 patients, 39 women and 24 men, were included in our study. The mean age of the patients was 47.8±11.2 years. The mean disease duration was 15.54±12 months. The trunk and thigh were the most commonly involved sites (49%, 33%). Associated conditions were identified in 52.3% of the patients. Infections (N = 16), malignancies (N = 6), rheumatic diseases (n=4) and drugs (n=4) were the most common precipitating factors respectively. The most common infections were superficial fungal infections and Helicobacter pylori infection. Histopathologically, 10 patients had deep type and 53 patients had superficial type EAC. We determined that the disease duration from the onset of the disease was longer (12.3 versus 16.2 months) and the number of attacks (1.2 versus 2.8 attacks) was higher in the superficial type when compared to the deep type (P = 0.042, P = 0.038).

CONCLUSIONS

In our study, infections, malignancies and rheumatic diseases were among the most common etiologic factors. We would also like to draw attention to Helicobacter pylori infection as a precipitating factor which may be a novel finding.

Dermatophyte Infections Worldwide: Increase in Incidence and Associated Antifungal Resistance

The increase in incidence of superficial fungal infections combined with the emergence of antifungal resistance represents both a global health challenge and a considerable economic burden. Recently, dermatophytes, the main culprit causing superficial fungal infections, have started to exhibit antifungal resistance. This can be observed in some of the most common species such as Trichophyton rubrum and Trichophyton mentagrophytes. Importantly, the new subspecies, known as Trichophyton indotineae, has been reported to show high resistance to terbinafine, a first-line treatment for dermatophyte infections. Compounding these issues is the realization that diagnosing the causative infectious agents requires using molecular analysis that goes beyond the conventional macroscopic and microscopic methods. These findings emphasize the importance of conducting antifungal susceptibility testing to select the appropriate antifungal necessary for successful treatment. Implementing these changes may improve clinical practices that combat resistant dermatophyte infections.

The Role of Sex and Gender in Dermatology - From Pathogenesis to Clinical Implications

BACKGROUND

Sex and gender have increasingly been recognized as significant risk factors for many diseases, including dermatological conditions. Historically, sex and gender have often been grouped together as a single risk factor in the scientific literature. However, both may have a distinct impact on disease incidence, prevalence, clinical presentation, severity, therapeutic response, and associated psychological distress.

OBJECTIVES AND PROJECT DESCRIPTION

The mechanisms that underlie differences in skin diseases between males, females, men, and women remain largely unknown. The specific objectives of this review paper are:To highlight the biological differences between males and females (sex), as well as the sociocultural differences between men and women (gender) and how they impact the integumentary system.To perform a literature review to identify important sex- and gender-related epidemiological and clinical differences for various skin conditions belonging to a range of disease categories and to discuss possible biological and sociocultural factors that could explain the observed differences.To discuss dermatological skin conditions and gender-affirming treatments within the transgender community, a population of individuals who have a gender identity which is different than the gender identity they were assigned at birth.

FUTURE IMPACT

With the rising number of individuals that identify as non-binary or transgender within our increasingly diverse communities, it is imperative to recognize gender identity, gender, and sex as distinct entities. By doing so, clinicians will be able to better risk-stratify their patients and select treatments that are most aligned with their values. To our knowledge, very few studies have separated sex and gender as two distinct risk factors within the dermatology literature. Our article also has the potential to help guide future prevention strategies that are patient-tailored rather than using a universal approach.

Annular Erythemas and Purpuras

Annular dermatoses are a heterogeneous and extremely diverse group of skin diseases, which share in common annular, ring-like patterns with centrifugal spreading. Numerous skin diseases can sometimes display annular lesions, but some specific skin conditions are originally annular. We take the opportunity to review here mainly the causes of primary annular erythemas and their differential diagnoses, but also the rare causes of annular purpuras.

Figurate erythemas and herpetic infection in children

Herpetic infections are distinguished by a diverse clinical picture — this is primarily the so-called «recurrent respiratory diseases» or a recurrent variant of a chronic infectious process in the form of a so-called «mononucleosis-like syndrome,» characteristic of almost every «herpetic nosology,» persistent subfebrile condition, and febrile condition. Often, against the background of herpetic infections, various kinds of exanthems manifest, and this is not only a vesicular rash during infection with the herpes simplex virus. In practice, pediatricians often have to deal with other types of exanthems, one way or another associated with herpes infections. The article discusses 2 clinical observations of relatively unusual manifestations of chronic herpetic infections accompanied by erythema in patients aged 16 years. Photo documents of the dynamics of the skin process and laboratory parameters against the background of antiviral therapy are presented. 

Uncommon non-infectious annular dermatoses

Several cutaneous diseases can present with annular lesions, making a distinction by physical appearance alone challenging. They can be distinguished into infectious and non-infectious, and common and uncommon annular dermatoses. Common non-infectious diseases include granuloma annulare, urticaria, and subacute lupus erythematosus. In addition, there are rare non-infectious non-neoplastic annular dermatoses whose nosographic attribution is established, including annually recurring erythema annulare centrifugum (EAC) and annular erythema in Sjögren syndrome and others whose nosographic positioning is still debated. They are neutrophilic figurate erythema, palpable migratory arciform erythema, eosinophilic annular erythema, and annular lichenoid dermatitis of youth. Their etiopathogenesis is largely unknown, although immune-mediated mechanisms are likely involved. It is difficult to establish if they are variants of reaction patterns or separate clinic-pathological entities. In fact, EAC and annually recurring EAC may represent different aspects of the same disease. Palpable migratory arciform erythema is hardly distinguishable from EAC deep type, Jessner-Kanof disease, and lupus tumidus. Neutrophilic figurate erythema and eosinophilic figurate erythema are clinically very similar and differing only in the relative proportion of eosinophils and neutrophils.

Paraneoplastic Erythema Annulare Centrifugum Eruption (PEACE) Associated With Metastatic Colorectal Adenocarcinoma

Erythema annulare centrifugum (EAC) is a figurate erythema presenting with annular, erythematous plaques with a trailing scale. It is considered a hypersensitivity reaction to a variety of antigens and is associated with multiple underlying causes including malignancy. Malignancy-associated EAC is termed paraneoplastic erythema annulare centrifugum eruption (PEACE). Although a specific etiology has yet to be elucidated, this form of EAC is likely to occur due to cytokine and/or antigen stimulation from an underlying malignancy. PEACE is primarily associated with lymphoproliferative disorders and rarely solid tumors. Our report discusses a case of PEACE associated with metastatic colorectal adenocarcinoma. On presentation to our clinic, the patient had developed a migratory annular eruption over a year. His review of symptoms was positive for signs of underlying malignancy, including weight loss and recent lower vertebral fracture. A biopsy of his annular lesion revealed a non-specific pityriasiform dermatitis. A vertebral biopsy uncovered a diagnosis of metastatic colorectal cancer. At that time, clinicopathologic correlation allowed us to reach the diagnosis of PEACE.

Eosinophilic annular erythema

Eosinophilic annular erythema (EAE) is a rare eosinophilic dermatosis characterized by annular, erythematous papules and plaques commonly found on the trunk and the extremities. There is continued debate on whether EAE is a distinct entity or a clinical polymorphism of Well's syndrome, but it is generally considered a separate entity based on clinical and histopathological differences. We present a case of EAE and discuss the histopathological findings.

Atypical erythema annulare centrifugum in a child with celiac disease

Herpetiformis dermatitis is the best characterized extraintestinal manifestation of celiac disease (CD). However, other chronic heterogeneous skin lesions have been associated with CD and should be considered in the differential diagnosis.

A 78-Year-Old Female with a Diffuse Pruritic Rash and Palmoplantar Desquamation

Mycosis fungoides, the most common cutaneous T-cell lymphoma, is known to exhibit varied clinical presentations and mimic many other dermatoses. This morphological heterogeneity can often lead to initial misdiagnoses resulting in significant delays from symptom onset to diagnosis. We report a case of mycosis fungoides imitating clinical and histopathological features of erythema annulare centrifugum.

An observational study of the efficacy of azithromycin in erythema annulare centrifugum

Erythema annulare centrifugum (EAC) is a form of figurate erythema consequent to a cutaneous hypersensitivity reaction to an underlying agent. In the present study, we aimed to assess the role of oral azithromycin in cases of idiopathic EAC. We performed an open trial of azithromycin in 10 patients with idiopathic EAC. Histopathological examination of biopsies was performed to exclude any alternative diagnosis and to assess the depth of the infiltrate. Patients were administered oral azithromycin 250 mg once daily until clinical resolution of the disease, and followed up regularly to monitor for possible relapse. Histopathological examination of the 10 biopsies revealed superficial pattern in 3, deep pattern in 2 and mixed pattern in the remaining 5. Of the 10 patients, 8 responded to azithromycin 250 mg, with no relapse during follow-up. Oral azithromycin might be a promising therapy in cases of idiopathic EAC. Cases with a superficial pattern respond earlier than cases with a deep pattern.

A case of tinea incognita and differential diagnosis of figurate erythema

A patient with tinea incognita is presented together with a review of the literature of figurate erythema. Figurate lesions are emblematic for dermatology and perhaps the most picturesque efflorescences. The differential diagnosis can be broad and sometimes challenging. Many clinical entities with resembling primary and secondary efflorescences have to be considered as differentials and can be due to anti-infectious, paraneoplastic, allergic, autoimmune or other immune reactions.

Erythromycin as a Safe and Effective Treatment Option for Erythema Annulare Centrifugum

Background:

Erythema annulare centrifugum (EAC) is an inflammatory dermatosis with unknown etiology. It is usually self-limited, but chronic disease may be difficult to treat. We observed incidentally the therapeutic effect of erythromycin for EAC among patients taking erythromycin for other diseases.

Aim:

To evaluate the treatment response of erythromycin for EAC.

Materials and Methods:

During the study period, from July 2007 to February 2011, all patients with EAC were assigned to erythromycin stearate tablet 1000 mg per day for two weeks. EAC was diagnosed by a constellation of clinical and pathological findings. The efficacy (before and after the treatment) was assessed clinically by one dermatologist and photographically by two blinded dermatologists. Secondary outcomes included adverse drug effects and recurrence.

Results:

Eight patients were enrolled in this study. Most patients had chronic relapsing disease with poor response to previous treatment. All the patients showed rapid response with profound reduction in the size of lesion and erythema two weeks after initiation of erythromycin treatment. The response was so obvious and complete that a coincidental response was less likely. Three patients had recurrence of disease and they tended to have more extensive lesions. Readministration of erythromycin was effective. All patients tolerated the treatment well.

Conclusion:

Our study documented erythromycin as a safe and cost-effective treatment for EAC.

Annually recurring erythema annulare centrifugum: a case report

Introduction

Erythema annulare centrifugum is a rare cutaneous disease characterized by erythematous and violaceous annular plaques that usually involved the thighs and the legs. The eruption may be associated with an underlying disease and its accompanying characteristic symptoms. For these reasons, a full physical examination should be conducted to exclude underlying disorders. Annually recurring erythema annulare centrifugum is a rare and peculiar variant of erythema annulare centrifugum with the same clinical and histopathological characteristics. The lesions of annually recurring erythema annulare centrifugum tend to regress spontaneously after a variable period of days to months with yearly recurrence for many years.

Case presentation

We present the case of a 46-year-old caucasian woman affected by annually recurring erythema annulare centrifugum, which is a peculiar form of superficial erythema annulare centrifugum. The lesions have the same clinical and histopathological characteristics of the classical superficial form of erythema annulare centrifugum and tend to regress spontaneously after a variable period of days to months. In our case, no precipitating factors were identified and no underlying diseases were found. Every year for the last 12 years the lesions started to appear in the summer months and regressed spontaneously in autumn.

Conclusions

Cases of annually recurring erythema annulare centrifugum are rarely reported in the literature and generally no causative agent can be detected. The main feature of annually recurring erythema annulare centrifugum is the constant annual and seasonal recurrence of the lesions for many years.

Systemic lupus erythematosus presenting as erythema annulare centrifugum

A case of systemic lupus erythematosus presenting as erythema annulare centrifugum involving atypical sites (face, palm and sole) and raised serum angiotensin-converting enzyme levels has been illustrated.

Erythema annulare centrifugum-like eruption associated with pegylated interferon treatment for hepatitis C

Current standard of treatment for chronic hepatitis C virus infection requires the use of pegylated interferon plus ribavirin. Treatment with these two agents has been associated with numerous side effects, which frequently include dermatologic eruptions. We report a cutaneous eruption associated with interferon having clinical presentation of erythema annulare centrifugum. The eruption occurred within days of the first interferon injection and repeatedly flared following subsequent injections. Our patient was able to continue therapy without interruption, while managing the reaction with topical corticosteroid and oral antihistamine. We conclude that this is a benign cutaneous eruption associated with interferon which can be managed without discontinuing treatment for hepatitis C.

Erythema annulare centrifugum as the presenting sign of Pseudomonas aeruginosa sepsis in a newborn

We report a case of erythema annulare centrifugum (EAC) with neonatal onset. The patient presented on the fourth day of life with erythematous papules that enlarged centrifugally to form annular or policyclic plaques on anterior surface of trunk and legs without signs of systemic toxicity. Subsequently, she developed sepsis and disseminated intravascular coagulation and died on the sixth day of life. Blood culture grew Pseudomonas aeruginosa. The coexistence of P. aeruginosa sepsis with the clinical appearance of erythema annulare centrifugum strongly suggests a pathogenetic effect of the microorganism on the skin eruption. To the best of our knowledge, this is the first report of EAC with P. aeruginosa sepsis in a newborn.

Erythema papulosa semicircularis recidivans: a new reactive dermatitis?

BACKGROUND

Nine patients with recrudescent and centrifugally expanded papuloerythematous eruptions were observed in our outpatient department during the recent 8 years. The patients were all young and middle-aged men presenting with characteristic skin lesions and relapsing each year in the warm humid season. Such an observation has not yet been described in the English literature.

OBJECTIVES

The objective of this study was to describe the clinical characteristics and explore the possible etiologies of our cases. In addition, differential diagnosis with other common figurate erythemas was also reviewed and discussed.

METHODS

In 5 of the patients, skin-prick testing was performed with common airborne and food allergens, and skin patch testing with the Chinese baseline series of contact allergens was performed, along with histopathologic examinations.

RESULTS

The skin findings in our patients were conspicuous in their papular characteristics of the borders, semicircular arrangement, male predominance, and yearly crescendo of recurrence in warm seasons. Histopathologic examination showed superficial perivascular dermatitis, whereas skin-prick testing and patch testing showed negative results.

CONCLUSIONS

Although the etiology of our cases remains unclear at present, the clinical characteristics make them distinct from other well-described figurate erythemas characterized by annular erythematous lesions. We propose the term erythema papulosa semicircularis recidivans to depict a special form of recurrent papuloerythematous figurate erythema of unknown etiology.

[Erythema annulare centrifugum. A clinical reaction pattern]

Erythema annulare centrifugum (EAC) is a clinical reaction pattern and not a specific clinicohistologic entity. The clinical and histologic differential diagnosis of EAC should take at least three main disease groups into consideration, which are often classified under this disorder: (tumid) lupus erythematosus, spongiotic dermatitides, and pseudolymphomas.

Annular erythema as a sign of recurrent breast cancer

Three women with known breast cancer presented with very similar annular erythemas of their chest walls. All women were in remission from their breast cancer for at least 6 months. Their breast cancers had initially responded well to multi-modality treatment with no clinical or radiologic evidence of recurrence, until the development of the annular erythema. In the first case, the annular erythema was treated unsuccessfully as a dermatitis and then as tinea corporis. In the second case, subacute cutaneous lupus was considered but lupus antibodies were negative. In the third case, the annular erythema was promptly recognized and biopsied. Histology in all three cases revealed identical findings of invasive ductal carcinoma involving the lymphatics of the skin. Immunohistochemical staining of the carcinoma was positive for human epidermal growth factor receptor 2 but negative for oestrogen and progesterone receptors. Annular erythema can pose a wide differential but rarely has it been described as a sign of locally recurrent cancer. These cases highlight the importance of recognizing this entity in the oncologic patient, where prompt skin biopsies can confirm the diagnosis and allow early initiation of therapy.

Erythema Annulare Centrifugum: A Rare Skin Finding of Autoimmune Hepatitis

Erythema annulare centrifugum is characterized by dermal perivascular lymphocytic infiltrates. It is often associated with infections, autoimmune or neoplastic diseases but in most cases the cause is unexplained. A case of erythema annulare centrifugum related to autoimmune hepatitis in a 24-year-old woman is described in this case report. Clinical response of the autoimmune hepatitis to a combination therapy with corticosteroids and azothiopurine was achieved. Although partially regressed for the first 12 months of theraphy, the skin lesions did not disappear completely. However, after 18 months of continious treatment there was no skin lesion.

Skin biopsy for inflammatory and common neoplastic skin diseases: optimum time, best location and preferred techniques. A critical review

The diagnosis of skin diseases, particularly inflammatory dermatoses, is based primarily on clinical information. Pathologic examination of the biopsied specimen often serves as a complementary or confirmative part of the diagnosis. However, the clinical diagnosis of skin diseases may be challenging, as the clinical information and appearance of skin lesions invariably overlap. Evidence for a correct diagnosis may be lacking without histopathologic examination of skin biopsies. It is well known that the histologic diagnosis of inflammatory and other skin diseases requires clinicopathologic correlation, and there is evolution of skin lesions into different stages as the diseases progress. Other factors important for accurate dermatopathologic diagnosis are optimum time, best location and preferred techniques of skin biopsy. In searching for available information concerning when, where and how to take skin biopsies, it is noted that there are only limited practical guidelines currently available. We present this review article in hopes that our collective dermatopathologic and dermatologic experience can provide a quick reference for accurate diagnosis and proper management of skin diseases.

Neutrophilic figurate erythema of infancy

We report here a new case of neutrophilic figurate erythema of infancy in a 1-year and 9-month-old white boy. Neutrophilic figurate erythema of infancy is a rare inflammatory dermatosis which is part of the figurate inflammatory dermatoses of infancy and is considered a variant of annular erythema of infancy. The disease is clinically characterized by annular erythematous lesions, sometimes with a polycyclic configuration, and histologically by a dermal neutrophilic infiltration with leukocytoclasia. Differential diagnosis mainly includes clear-cut severe diseases with a well-known etiology, such as neonatal lupus erythematosus and its variant erythema gyratum atrophicans transiens neonatale, erythema chronicum migrans and erythema marginatum rheumaticum, and diseases of unknown origin and with less clear limits, such as erythema annulare centrifugum and its variant familial annular erythema. Anamnesis, laboratory findings, clinical features, and histology allow the correct diagnosis and therefore, having excluded severe diseases, parents should be reassured as neutrophilic figurate erythema of infancy, as the annular erythema of infancy, is a benign disease, in most cases unassociated with other conditions and usually self-limiting over a few months, even though a chronic course may rarely occur. Our case was characterized by a chronic persistent course and by a complete resolution of the lesions only during febrile episodes.