Indian Journal of Dermatology
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CASE REPORT
Year : 2009  |  Volume : 54  |  Issue : 5  |  Page : 24-26
Erythema gyratum repens-like atypical and persistent figurate erythema


1 Department of Dermatology, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
2 Department of Pathology, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey

Correspondence Address:
Zehra Asiran Serdar
Department of Dermatology, Haydarpasa Numune Training and Research Hospital, 34746 Üsküdar, Istanbul
Turkey
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Source of Support: None, Conflict of Interest: None


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   Abstract 

Figurate erythemas are a group of dermatoses mostly developing in response to an underlying condition. They are characterized by erythematous papules growing centrifugally to form annular or polycyclic figures. Here, we describe a 16-year-old girl with EGR-like lesions confined to the dorsum of hands, present since she was eight years of age.


Keywords: Annular erythema, childhood, erythema gyratum repens


How to cite this article:
Serdar ZA, Mansur AT, Yasar SP, Endogru E, Gunes P. Erythema gyratum repens-like atypical and persistent figurate erythema. Indian J Dermatol 2009;54, Suppl S1:24-6

How to cite this URL:
Serdar ZA, Mansur AT, Yasar SP, Endogru E, Gunes P. Erythema gyratum repens-like atypical and persistent figurate erythema. Indian J Dermatol [serial online] 2009 [cited 2019 Oct 19];54, Suppl S1:24-6. Available from: http://www.e-ijd.org/text.asp?2009/54/5/24/45437



   Introduction Top


Figurate erythemas are a group of dermatoses mostly developing in response to an underlying condition. They are characterized by erythematous papules growing centrifugally to form annular or polycyclic figures. [1]


   Case History Top


A 16-year-old, otherwise healthy-looking girl was admitted to our clinic with asymptomatic erythematous plaques forming concentric rings on dorsa of both hands. They were mainly confined to hands, only partially spreading to the dorsal surfaces of the wrists and forearms. The patient described that the lesions were less prominent during summer months and became more erythematous during winter and after contact with water. The only complaint of her was the disfigurement caused by the lesions. Her past medical history was unremarkable with no specific medication. Family history was not contributory. Systemic medical examination revealed normal findings.

On dermatological examination, well-defined, concentric, slightly elevated, wavy plaques, with peripheral fine scale were found on dorsal aspects of the hands, wrists and distal parts of forearms. The lesions had a striking, target board or "wood grain" appearance [Figure 1],[Figure 2]. The rest of the skin, oral and genital mucosa, skin appendages including scalp hair, body hair, and nails were normal. Dermographism was negative.

Potassium hydroxide examination of the scrapings did not reveal any hyphae or spore. Complete blood cell count, peripheral blood smear, chemistry battery, serum thyroid hormone, TSH, vitamin B12, folic acid levels, urinalysis, stool tests for parasites and occult blood, erythrocyte sedimentation rate, ANA, RF, RPR, AntiHIV, C3, C4, serology for viral hepatitis B and C, were within normal limits or negative. PPD was 10mm. Chest X-ray was normal with no evidence in favor of active or previous tuberculosis.

Histopathologically, hyperkeratosis, focal parakeratosis, hypergranulosis, focal and mild perivascular lymphocyte infiltration at papillary dermis were noticed [Figure 3]. Direct immunofluorescence study was nonspecific, with fine, dusty precipitates at dermoepidermal junction on C3 staining.


   Discussion Top


Classification of figurate erythemas is among the most complicated and controversial issues in dermatology. Under this heading several entities including erythema annulare fentrifugum, erythema gyratum repens, erythema chronicum migrans, erythema marginatum, annular erythema of infancy, erythema gyratum atroficans neonatale, and familial annular erythema were described. [2]

As the microscopic findings of these disorders are nonspecific and similar, clinical characteristics are more important for the differential diagnosis.

Erythema gyratum repens is characterized by multiple, annular, rapidly growing erythematous plaques with a trailing scale. [3] The whole pattern of the eruption resembles wood grain. The lesions are mostly located on the trunk and extremities, and rarely involve hands, feet and face. The patients frequently complain of itching. [4] This specific entity of figurate erythemas usually appears in the middle-aged or elderly individuals. To the best of our knowledge, it has not been reported in the pediatric age group. [4],[5] The clinical appearance of our case closely resembles EGR. On the other hand, onset in childhood, confinement to hands, spontaneous amelioration at certain seasons, and lack of itching are not usual for EGR.

Although the etiology of EGR is not known, in more than 80% of the cases, an underlying malignancy is found. So it is considered as the most specific paraneoplastic syndrome. However, there are some cases without malignancy which are instead, associated with pulmonary tuberculosis. [6] In addition, EGR-like lesions have been reported in association with ichthyosis, palmoplantar keratosis, pityriasis rubra pilaris, psoriasis, lupus erythematosus, leucocytoclastic vasculitis and CREST syndrome. Rarely, EGR has been reported in healthy individuals. [3],[7],[8],[9] In our case, clinical and laboratory investigations did not reveal any underlying disease or malignancy. Moreover, the above mentioned dermatoses mimicking EGR could be excluded by clinical, histopathologic and direct immunofluorescence findings of the lesions.

Among figurate erythemas, EAC is the second important type, which should be considered in the differential diagnosis of our case. It starts with erythematous papules that spread peripherally. While the primary lesion enlarges, central healing occurs to produce figurate, circinate, and polycyclic rings. The superficial form of EAC has a trailing scale on the inner aspect of the advancing border and the lesions are usually pruritic. Individual lesions of EAC may persist for several days, and then disappear to be replaced by new lesions. The eruption has a chronic and relapsing course, over months to years. The disease has a predilection for the trunk and proximal extremities, especially thighs and legs, but it may occur on the upper extremities and the face, mostly in an asymmetric pattern. The palms and soles are spared. [4] Though its peak of incidence is between 30 and 50years of life, EAC has been reported also in childhood. [2],[3] In our patient, concentric bands not forming polycyclic rings, absence of pruritus, the clearly symmetric distribution, the localization and persistence at a specific site are not typical for EAC.

We could be able to rule out other figurate erythemas, including erythema chronicum migrans, a skin finding at early stages of borreliosis, and erythema marginatum, the rapidly disappearing erythematous rash of acute rheumatic fever, by clinical and laboratory data of our patient.

Certain clinical presentations, which do not fit any of the above mentioned classical figurate erythema types, with congenital and/or infancy onset and characterized by annular erythematous lesions mostly regressing during childhood, have been described. There are also a few reports of congenital annular erythema persisting until adolescence, or even adulthood. However, late onset of the lesions (8 y) distinguishes our patient from those cases.

Figurate erythemas often represent an underlying infectious disease, malignancy or drug/food intake. Elimination of the cause results improvement. [6] In cases with EGR where the eruption preceded detection of malignancy, the time interval varied from one month to 21 months. [3] Our case did not develop any evidence in favor of malignancy, although eight years had passed over the onset of lesions, indicating that it was not a paraneoplastic condition. Detailed investigation did not also reveal a sign of any other underlying disease.

An interesting point of our case was the waning of lesions during summer months, suggesting a therapeutic effect of ultraviolet light. We are unaware of reports on the effects of phototherapy and/or photochemotherapy in the treatment of figurate erythemas, except for the treatment of EAC-like psoriasis.

In conclusion, the presented case had an EGR-like figurate erythema that commenced in childhood and persisted, with no identifiable underlying cause. In light of the atypical clinical presentation of the case, rendering it impossible to categorize according to current classifications, we conclude that figurate erythemas could be considered as a spectrum, sometimes with overlapping features.

 
   References Top

1.Kurzrock R, Cohen PR. Erythema gyratum repens. JAMA 1995;273:594.  Back to cited text no. 1  [PUBMED]  
2.Duarte AM. Annular erythemas. In : Harper J, Oranje A, Prose N, editors. Textbook of Pediatric Dermatology. London: Blackwell Science Ltd; 2000. p. 610-5.  Back to cited text no. 2    
3.Bolognia JL, Jorizzo JL, Rapini RP, Erythemas. In: Espana A, editor. Dermatology. 1st Edinburg: Mosby; 2003. p. 303-11.  Back to cited text no. 3    
4.Wong LC, Kakakios A, Rogers M. Congenital annular erythema persisting in a 15-year-old girl. Australas J Dermatol 2002;43:55-61.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Bottoni U, Innocenzi D, Bonaccorsi P, Carlesimo M, Faina P, Richetta A. Erythema annulare centrifugum: Report of a case with neonatal onset. JEADV 2002;16:500-3.  Back to cited text no. 5    
6.Eubanks LE, Mcburney E, Reed R. Erythema gyratum repens. Am J Med Sci 2001;321:302-5.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]
7.Jablonska S, Blaszczyk M, Kozlowska A. Erythema gyratum repens-like psoriasis. Int J Dermatol 2000;39:695-7.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]
8.Stankler L. Erythema gyratum repens: Spontaneous resolution in a healthy man. Br J Dermatol 1978:99;461.  Back to cited text no. 8    
9.Langlois JC, Shaw JM, Odland GF. Erythema gyratum repens unassociated with internal malignancy. J Am Acad Dermatol 1985;12:911-3.  Back to cited text no. 9  [PUBMED]  


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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    Abstract
    Introduction
    Case History
    Discussion
    References
    Article Figures

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