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Dermatology > REACTIVE AND INFLAMMATORY DERMATOSES
Erythema Annulare Centrifugum
Article Last Updated: Apr 11, 2006
AUTHOR AND EDITOR INFORMATION
Section 1 of 11  
Author: Robert J Willard, MD, Consulting Dermatologist, West Kentucky Dermatology, LLC
Robert J Willard is a member of the following medical societies: American College of Physicians and American Medical Association
Coauthor(s):
Andrew D Montemarano, DO, Consulting Staff, The Skin Cancer Surgery Center
Editors: Evan R Farmer, MD, Professor of Dermatology, Johns Hopkins University School of Medicine, Clinical Professor of Pathology, Virginia Commonwealth University School of Medicine; Consulting Staff, Department of Dermatology, Johns Hopkins Hospital, VCU Health Services; Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center; Warren R Heymann, MD, Head, Division of Dermatology, Professor, Department of Internal Medicine, University of Medicine and Dentistry of New Jersey; Joel M Gelfand, MD, MSCE, Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania; William D James, MD, Paul R Gross Professor of Dermatology, University of Pennsylvania School of Medicine; Vice-Chair, Program Director, Department of Dermatology, University of Pennsylvania Health System
Author and Editor Disclosure
Synonyms and related keywords:
EAC, erythema gyratum perstans, erythema exudativum perstans, erythema marginatum perstans, erythema perstans, erythema figuratum perstans, erythema microgyratum perstans, erythema simplex gyratum
Background
Erythema annulare centrifugum (EAC) is classified as one of the figurate or gyrate erythemas. First described by Darier in 1916, it is characterized by a scaling or nonscaling, nonpruritic, annular or arcuate, erythematous eruption. It tends to spread peripherally while clearing centrally. Histologically, an intense lymphohistiocytic cuffing occurs about the superficial and deep dermal vessels without epidermal involvement. The etiology is uncertain, but it may be due to a hypersensitivity to malignancy, infection, drugs, or chemicals, or it may be idiopathic. Controversy exists in the classification of the gyrate erythemas, and the literature is wrought with ambiguity and contradictions. Since its initial description in 1916, the term erythema annulare centrifugum has grown to include several histologic and clinical variants. Ackerman, and later Bressler and Jones,1 suggested a classification in which only 2 types of gyrate erythema are considered: superficial (pruritic, scaling) and deep (nonpruritic, nonscaling). The original description of EAC was of the latter type. However, the superficial type is more commonly seen with its characteristic trailing scale behind an advancing, erythematous border. In this article, EAC is considered to include all the gyrate erythemas, except for erythema marginatum rheumaticum, erythema chronicum migrans, and erythema gyratum repens. When taken in this broad sense, EAC can be scaly or nonscaly, pruritic or nonpruritic, and rarely vesicular.
Pathophysiology
The pathogenesis of EAC is unknown, but it is probably due to a hypersensitivity reaction to a variety of agents, including drugs, arthropod bites, infections (bacterial, mycobacterial, viral, fungal, filarial), ingestion (blue cheese Penicillium), and malignancy. Injections of Trichophyton, Candida, tuberculin, and tumor extracts have been reported to induce EAC, supporting a type IV hypersensitivity reaction as at least one mechanism for its development. Other cases have been found in association with an underlying systemic disease (eg, liver disease,2 Sjögren syndrome, systemic lupus erythematosus, Graves disease,3 hypereosinophilic syndrome,4 appendicitis5). Still others have been attributable to a familial form. However, in most cases, no underlying cause can be found. One study of 24 cases of EAC with special reference to its association with an underlying disease found no increased incidence of systemic disease, malignancy, or infection. In another study of 113 cases of gyrate erythemas, 7 cases (none of which was erythema gyratum repens) were associated with internal malignancy compared with 6 cases in the control group. Hypotheses about the mechanism of annularity focus on the interaction between mediators of inflammation and ground substance as foreign antigens diffuse through the skin.
Frequency
International
Defining the incidence and the prevalence of EAC is difficult because the literature mostly consists of case reports and brief reviews. In a review of 24 cases in England, the incidence was reported to be approximately 1 case per 100,000 population per year in a catchment area of 500,000 people.
Mortality/Morbidity
The mean duration of EAC is 11 months. However, the course has ranged from 4-6 weeks to 34 years (recurrent attacks). Most cases require no treatment and resolve spontaneously. Others have been reported in association with malignancy, with the eruptions responding to treatment of the underlying neoplasm. In those cases, the prognosis is affected by the underlying malignancy.
Race
Whether any racial predilection exists is not known.
Sex
No bias for either sex is apparent.
Age
EAC has been reported in patients from infancy to the ninth decade of life.
History
- Usually, the patient presents with an asymptomatic or pruritic eruption of variable duration. The eruption may be associated with an underlying disease (eg, infection, malignancy, sarcoidosis, other systemic illness) and its accompanying characteristic symptoms (eg, night sweats, fever, and chills for tuberculosis or Hodgkin lymphoma).
- EAC may precede malignancy by 2 years or more, but it can also occur concomitantly or after diagnosis.
- The temporal relationship to other underlying diseases, if any, is also variable. Obtain a history of any antecedent infections.
- A history of recent initiation of a new drug should be ascertained because many reports of medication-associated EAC exist (most commonly antimalarials, cimetidine, spironolactone, gold, salicylates, piroxicam, penicillin, and amitriptyline).
- One case report6 has described EAC as a manifestation of autoimmune progesterone dermatitis in a female with a recurring annular pruritic eruption. She experienced monthly exacerbations of the eruption a few days prior to onset of menses. A similar hormonal etiology has been reported in the case of a woman who developed EAC in the 33rd week of pregnancy. The eruption resolved 1 month after delivery, without recurrence after 8 months of follow-up.
Physical
Pertinent physical findings are usually limited to the skin, but a full physical examination should be conducted to assess for an underlying systemic process.
- Skin
- Primary lesion: The eruption begins as erythematous papules that spread peripherally while clearing centrally. These lesions enlarge at a rate of approximately 2-5 mm/d to produce annular, arcuate, figurate, circinate, or polycyclic plaques. The margin, which is usually indurated, varies in width from 4-6 mm, and, often, a trailing scale is present on the inner aspect of the advancing edge. The diameter of the polycyclic lesions varies from a few to several centimeters. Vesiculation may be present.
- Distribution: Lesions demonstrate a predilection for the thighs and the legs, but they may occur on the upper extremities, the trunk, or the face. The palms and the soles are spared.
- Color: The lesions are pink to red with central clear areas. Occasionally, residual hyperpigmentation of dull red, brown, or violet is present. A case of EAC associated with hyperbilirubinemia and jaundice secondary to choledocholithiasis has been reported.
- Nails: White banding of the toenails has been reported in association with EAC.
- Lymph nodes: Lymphadenopathy may be present in cases of EAC associated with Hodgkin or non-Hodgkin lymphoma, tuberculosis, or autoimmune processes.
- Neck: The thyroid should be palpated for enlargement or nodules because Graves disease has been associated with EAC.3
- Lungs: Tuberculosis,7 lymphoma, sarcoidosis, and malignant bronchial carcinoid have been associated with EAC, warranting examination of the lungs.
- Abdomen: Appendicitis,5 lymphoma (with associated splenomegaly), and liver disease2 (eg, cholelithiasis, hepatitis), and pregnancy have been reported with EAC. The abdomen should be examined for tenderness, masses, or hepatosplenomegaly.
Causes
Most commonly, no cause is found. However, the literature contains numerous case reports documenting association with other diseases. Often, the eruption of EAC resolves after treatment of the underlying illness.
- Infections
- Bacteria: Associations include Escherichia coli. One case associated EAC with a urinary tract infection that cleared 3 weeks after treatment of the urinary tract infection. Other associated bacterial infections include streptococcal infections (eg, bacterial meningitis.
- Fungi: Dermatophytes (Trichophyton, tinea pedis, Pityrosporum orbiculare/Malassezia furfur) are associated, as is Candida albicans and blue cheese Penicillium.
- Mycobacteria: Mycobacterium tuberculosis is associated. Treatment with isoniazid, rifampin, and streptomycin cleared the eruption of EAC within 20 day of starting therapy for tuberculosis in a patient.
- Parasites: These include Ascaris lumbricoides; EAC resolved after treatment with piperazine and thiabendazole. Also, EAC has recently been reported in association with Phthirus pubis infestation.
- Viruses: EAC has been reported in association with Epstein-Barr virus (EBV) in an infant and with molluscum contagiosum in an 8-year-old child. In the infant, the appearance and subsequent resolution of the eruption coincided with the patient's anti-EBV antibody titer, supporting EBV as the inciting agent. In addition, the viral genome has been found in the DNA of Reed-Sternberg cells in patients with Hodgkin disease and in patients with nasopharyngeal carcinoma. Both of these neoplasms have been associated with EAC. Two cases of EAC were reported in a dermatomal distribution within the exact distributions of recent prior herpes zoster infections. These cases were cited as examples of "Wolf's isotopic response."
- Drugs: In each of the following cases, the eruption of EAC appeared after initiation of the drug and resolved after its cessation. In the cases of the antimalarials chloroquine and hydroxychloroquine, the eruptions took 5 months to a year to clear, believed to be secondary to their strong DNA-binding properties and affinity for melanin.
- Chloroquine
- Hydroxychloroquine
- Estrogen
- Cimetidine
- Penicillin
- Salicylates
- Piroxicam
- Hydrochlorothiazide
- Gold sodium thiomalate
- Amitriptyline
- Etizolam
- Neoplasms: In each of the following cases, EAC resolved with successful treatment of the malignancy but relapsed with tumor recurrence in the cases of Hodgkin disease, acute myelogenous leukemia (AML), and squamous cell carcinoma in a sebaceous cyst. However, in the latter case, EAC cleared in the terminal stage of the disease. This was purported to be due to immune compromise with tumor progression.
- Squamous cell carcinoma (in a sebaceous cyst)
- Nasopharyngeal carcinoma
- Acute myelogenous leukemia
- Peritoneal carcinomatosis
- Primary bronchial carcinoid
- Hodgkin lymphoma
- Multiple myeloma
- Prostate cancer
- Malignant histiocytosis
- Ovarian carcinoma (mucinous)
- Foods: Blue cheese and tomatoes have been reported to cause EAC.
- Other causes
- Recurrent acute appendicitis: The lesions of EAC resolved 1 month after appendectomy.5
- Cholestatic liver disease (secondary to choledocholithiasis): EAC resolved within 3 days of removal of the stone.2
- Graves disease: The patient's eruption disappeared 2 weeks after treatment with I-131 for thyroid ablation.3
- Menstruation: A case has been reported of a woman with EAC whose lesions stopped progressing premenstrually and enlarged again with the onset of menses. Another patient experienced exacerbations of EAC premenstrually as a type of autoimmune progesterone dermatitis.6
- Hypereosinophilic syndrome: A patient with 31% eosinophilia (with no underlying cause found), pruritus, and EAC was treated with ketoconazole, dapsone, and trimethoprim-sulfamethoxazole with resolution of the eruption occurring after 2 weeks.4
- Sjögren syndrome
- Sarcoidosis: EAC was reported in association with underlying systemic sarcoidosis.
- Osteoarthritis: A 73-year-old man with an 11-week history of EAC that was associated with the onset of left knee osteoarthritis received injections of intra-articular hyaluronic acid that effected resolution of both his osteoarthritis and the EAC.8
Cutaneous T-Cell Lymphoma
Erythema Gyratum Repens
Granuloma Faciale
Lupus Erythematosus, Subacute Cutaneous
Other Problems to be Considered
- Annular urticaria
- Benign lymphocytic infiltrate
- Erythema migrans: These lesions are typically less numerous, less circinate in configuration, and often accompanied by a history of a tick bite (Ixodes scapularis).
- Erythema gyratum repens: EAC can be distinguished from this condition by its slower rate of spread (weeks rather than days) and by its less bizarre configuration. Also, erythema gyratum repens is almost always associated with an underlying malignancy.
- Erythema marginatum rheumaticum: This is a nonscaling gyrate erythema that by definition is found in association with rheumatic fever (10-18% of patients with rheumatic fever). The rate of spread is measurable in hours, and the skin infiltrate is neutrophilic as opposed to lymphohistiocytic.
- Facial granuloma
- Subacute cutaneous lupus erythematosus (annular variant): These lesions tend to coalesce and can be accompanied by central hypopigmentation and telangiectasias.
Lab Studies
- Skin scrapings from lesional sites should be analyzed after preparation in potassium hydroxide (KOH) to ascertain the presence or the absence of hyphae suggestive of tinea or candidiasis.
- Lyme antibody titer is needed to exclude erythema migrans.
- An antinuclear antibody test should be performed in the appropriate clinical setting. Systemic lupus erythematosus is in the differential diagnosis of EAC, and Sjögren syndrome has been reported in association with EAC.
- A purified protein derivative (PPD) test and an anergy panel can be used to determine if an underlying M tuberculosis infection is present.
- A complete blood count with differential can be used to determine a suspected underlying infection (neutrophilia with bacterial infection; eosinophilia with parasitic infection or hypereosinophilic syndrome).
- If compatible with the clinical presentation, liver function studies may be useful because hyperbilirubinemia secondary to cholestasis and elevated transaminase levels secondary to hepatitis have been reported with EAC.
- With an appropriate history of gastrointestinal complaints, a stool examination may be useful to search for ova and parasites (ascariasis has been reported with EAC).
- For females, serum or urine beta-human chorionic gonadotropin testing may be indicated.
Imaging Studies
- Chest radiography can be used to exclude pulmonary nodules or hilar adenopathy suggestive of tuberculosis, malignancy (primary or metastatic), sarcoidosis, or lymphoma, all of which have been associated with EAC.
Procedures
- A skin punch biopsy may be performed.
Histologic Findings
A biopsy is helpful in confirming a diagnosis of EAC. Two histologic subtypes exist: deep and superficial. In the classic or deep type, an intense, superficial and deep lymphocytic or lymphohistiocytic perivascular infiltrate in a coat-sleeve fashion is observed in the middle and lower dermis. No epidermal changes are observed. Clinically, these lesions have indurated borders and are nonscaly and nonpruritic.
In the superficial type, a more nonspecific perivascular lymphohistiocytic infiltrate about the superficial dermal vessels and edema of the papillary dermis is present. The epidermal changes of parakeratosis and spongiosis may be present. Clinically, these lesions have a scale, may be pruritic, and may have vesiculations.
Medical Care
EAC is usually self-limited. Topical steroids usually cause involution of the treated lesions, but they do not prevent the occurrence of new lesions. Systemic or injection steroid therapy is effective, but the eruption returns once these drugs are withdrawn. As previously mentioned, several cases of EAC have resolved once the underlying diseases were treated. Therefore, a search for and treatment of the underlying disorder is the primary therapy. However, an exhaustive workup for occult malignancy is not warranted because the relationship between EAC and cancer is not consistent. Remember that no cause is found in most cases. The patient's medications should be reviewed with particular attention to and discontinuation of the drugs known to be associated with EAC. Recent additions to the patient's drug regimen should be eliminated, and the patient should be observed for signs of resolution. In a case of EAC associated with hypereosinophilic syndrome, the eruption resolved after treatment with ketoconazole, dapsone, and trimethoprim-sulfamethoxazole.4 A case of EAC of infantile onset in the French literature documents dramatic improvement with interferon alpha therapy.9 Three recent case reports have documented success in the treatment of EAC with drugs previously unreported to be useful for EAC.
- Hyaluronic acid: A 73-year-old man with an 11-week history of EAC that was associated with the onset of left knee osteoarthritis received injections of intra-articular hyaluronic acid that effected improvement of his osteoarthritis and resolution of his EAC.8
- Calcipotriol: A case of EAC of 3 years' duration in a 73-year-old woman responded to calcipotriol after the patient did not respond to topical and systemic corticosteroids, antifungals, and psoralen with UV-A therapy. The eruption cleared completely after 3 months of treatment with calcipotriol.10
- Metronidazole: A 38-year-old man with a 2-year history of EAC for which an underlying cause could not be found and that failed to respond to systemic antibiotics (ie, ciprofloxacin, clarithromycin), antifungal agents (ie, itraconazole, terbinafine), and topical calcipotriol did respond to oral metronidazole. The drug had been given to treat papulopustular rosacea. His EAC was coincidentally found to resolve, as did his rosacea, after 1 month of therapy. No recurrence of EAC was noted after 1 year of follow-up. A possible causal relationship between rosacea and EAC was postulated in the report.11
Consultations
- Consult a dermatologist for diagnosis and evaluation of the underlying cause of EAC.
- Consult an internal medicine specialist for evaluation of the underlying cause of EAC.
The goals of pharmacotherapy are to reduce morbidity and to prevent complications.
Drug Category: Corticosteroids
Topical agents are used for treatment of inflammatory lesions of EAC and for symptomatic relief of pruritus. A short course of systemic steroid therapy may be considered for very symptomatic cases of EAC (eg, severe pruritus).
| Drug Name | Fluocinonide (Fluonex, Lidex) |
|---|
| Description | A group II topical steroid. The anti-inflammatory potency group is determined by the degree of vasoconstriction induced by the drug in the small vessels of the upper dermis (I is most potent; VII is least potent). Use drug in all involved areas except those where the skin is particularly thin (eg, face, scrotum, axilla, flexural areas). |
|---|
| Adult Dose | 0.05% cream applied to affected areas bid until lesions resolve or for 4 wk; not to exceed 50-60 g/wk |
|---|
| Pediatric Dose | Not recommended |
|---|
| Contraindications | Documented hypersensitivity; herpes simplex infection; fungal, viral, or tubercular skin lesions |
|---|
| Interactions | None reported |
|---|
| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
|
|---|
| Precautions | Children may be more susceptible to topical steroid-induced adrenal suppression and Cushing syndrome than adults because of their greater skin surface area to body weight ratio; skin atrophy occurs with prolonged use (4-8 wk) |
|---|
| Drug Name | Hydrocortisone valerate (Westcort) |
|---|
| Description | Group V topical steroid. The anti-inflammatory potency group is determined by the degree of vasoconstriction induced by the drug in the small vessels of the upper dermis (I is most potent; VII is least potent). This topical corticosteroid should be used on involved areas of the skin that are particularly thin, such as the face, axilla, scrotum, and flexural areas. |
|---|
| Adult Dose | 0.2% cream applied to affected areas bid until resolution occurs or for 4 wk |
|---|
| Pediatric Dose | Apply as in adults; may need to taper applications to minimize risk of adrenal suppression |
|---|
| Contraindications | Documented hypersensitivity; viral, fungal, or tubercular skin infections |
|---|
| Interactions | Corticosteroid clearance may decrease with estrogens; may increase digitalis toxicity secondary to hypokalemia |
|---|
| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
|
|---|
| Precautions | Caution in hyperthyroidism, osteoporosis, peptic ulcer, cirrhosis, nonspecific ulcerative colitis, diabetes, and myasthenia gravis; children may be more susceptible to topical steroid-induced adrenal suppression and Cushing syndrome than adults because of their greater skin surface area to body weight ratio; skin atrophy occurs with prolonged use (6-8 wk) |
|---|
| Drug Name | Prednisone (Deltasone) |
|---|
| Description | Immunosuppressant for treatment of autoimmune disorders. May decrease inflammation by reversing increased capillary permeability and suppressing PMN activity. Stabilizes lysosomal membranes and also suppresses lymphocyte and antibody production. |
|---|
| Adult Dose | 0.5-1 mg/kg/d PO every am for 7-21 d; taper as condition improves; single morning dose is safer for long-term use, but divided doses have more anti-inflammatory effect |
|---|
| Pediatric Dose | Not established |
|---|
| Contraindications | Documented hypersensitivity; viral, fungal, tubercular skin, or connective tissue infections; peptic ulcer disease; hepatic dysfunction; GI tract disease; administration of live virus vaccines to patients receiving immunosuppressive corticosteroids |
|---|
| Interactions | Coadministration with estrogens may decrease clearance; when used with digoxin, digitalis toxicity secondary to hypokalemia may increase; phenobarbital, phenytoin, and rifampin may increase the metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics |
|---|
| Pregnancy | B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
|
|---|
| Precautions | Prolonged use (>21 d) requires tapering secondary to adrenal suppression; abrupt discontinuation after prolonged use of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur; may mask signs of infection |
|---|
Prognosis
- The prognosis is excellent, except when associated with an underlying malignancy and other systemic disease.
Medical/Legal Pitfalls
- Failure to make the diagnosis. Underlying diseases should be ruled out.
| Media file 1:
Arcuate lesions of erythema annulare centrifugum demonstrate minimal scale. |
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Media type: Photo
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| Media file 2:
Superficial erythema annulare centrifugum demonstrates a central clearing and trailing scale behind an advancing, annular, erythematous border. |
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Media type: Photo
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Erythema Annulare Centrifugum excerpt Article Last Updated: Apr 11, 2006
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