Erythema gyratum repens is the only annular erythema covered in this chapter that has not yet been reported in children. Erythema migrans is the most frequently encountered annular erythema in the pediatric population covered in this chapter.
Erythema annulare centrifugum
History.
Darier first used the term erythema annulare centrifugum in 1916 [1,2]. This eruption is considered a reactive migratory annular erythema which occurs more commonly in adults. However, cases have been reported in newborn infants, children and families [3–7]. Some authors divide erythema annulare centrifugum into two clinically and histologically distinct variants: a superficial form and a deep form [8,9].
Aetiology.
Most authors believe erythema annulare centrifugum is a cutaneous hypersensitivity reaction to an underlying agent [2]. Unfortunately, an aetiological agent is often not identified [10]. Erythema annulare centrifugum has been associated with several infections including Epstein–Barr virus, herpes zoster, molluscum contagiosum, candidiasis, dermatophytosis, ascariasis and tuberculosis [1,5,7,11–16]. Drugs that have been associated with erythema annulare centrifugum include etizolam, piroxicam, amitriptyline, hydroxycholoroquine sulfate, hydrochlorothiazide and cimetidine [1,17–22]. Other associated conditions include sarcoidosis, liver disease, thyroid disorders and hypereosinophilic syndrome [23–26]. Rarely, malignancies such as Hodgkin disease, multiple myeloma, leukemia, prostate carcinoma, nasopharyngeal carcinoma and squamous cell carcinoma have been associated with erythema annulare centrifugum [1,27–31]. Interestingly, there has been one report of an associated food hypersensitivity to Penicillium mould found in blue cheese [32].
Pathology.
Histologically, erythema annulare centrifugum has been separated into superficial and deep variants on the basis of the distribution of the perivascular infiltrate [1,9,33]. The superficial variant displays focal spongiosis, parakeratosis and a lymphohistiocytic perivascular infiltrate surrounding the superficial vascular plexus [9,33]. The deep variant lacks epidermal change and has a tightly cuffed, ‘coat-sleeve’, superficial and deep perivascular lymphohistiocytic infiltrate [9,33].
Laboratory Studies.
There are no specific laboratory features. If laboratory abnormalities are present, they may be reflective of an associated underlying disorder [2].
Clinical Features.
Erythema annulare centrifugum begins as an erythematous papule that slowly migrates (2–3 mm/day) and peripherally enlarges into an arcuate or polycyclic lesion with central clearing (Fig. 76.2) [2,34]. Lesions can reach up to 10 cm in diameter and are located predominantly on the trunk and proximal extremities [2]. The superficial variant of erythema annulare centrifugum may have a pruritic border with trailing scale and rare vesicles [2,8,27]. The deep variant lacks scale or pruritus and has a firm indurated border [2,8,27]. Individual lesions may resolve within days to weeks while new lesions continue to emerge [10,27].
Fig. 76.2 Erythema annulare centrifugum with fine scaling in the inner aspect of the advancing palpable border.
Courtesy of Professor J. Harper.
Prognosis.
Erythema annulare centrifugum may be persistent, lasting from several weeks to several years, until eventual spontaneous regression occurs [10,27]. Annually recurring erythema annulare centrifugum has been reported in adults [35]. The clinical course may also parallel that of an associated underlying disorder [2].
Treatment.
Symptomatic treatment with antihistamines or topical steroids may provide some relief; however, treatment will not affect the chronic and recurrent nature of the condition [1,27]. Case reports of erythema annulare centrifugum responding to topical calcipotriol or topical tacrolimus have been reported [36,37]. Treatment of an associated underlying condition may lead to resolution of the eruption [2].
Differential Diagnosis.
The differential diagnosis of the superficial variant of erythema annulare centrifugum includes: tinea corporis, subacute cutaneous lupus erythematosus, neonatal lupus erythematosus, pityriasis rosea, erythema gyratum repens, drug eruption and psoriasis [1,34,38]. The differential diagnosis of the deep variant of erythema annulare centrifugum includes erythema migrans, erythema marginatum, urticaria, granuloma annulare, erythema multiforme, sarcoidosis, borderline and lepromatous leprosy, and annular erythema of infancy [1,34,38].
References
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