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E-IJD® - QUIZ |
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| Year : 2022 | Volume
: 67
| Issue : 6 | Page : 838 |
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| Annular erythematous skin lesions in a 51-year-old man |
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Rim Chaabouni1, Emna Bahloul1, Ibticem Bahri2, Khadija Sellami1, Tahiya Boudawara2, Hamida Turki1
1 Departments of Dermatology, Hedi Chaker Hospital, Faculty of Medicine, University of Sfax; Laboratory of Pathological Anatomy, Habib Bourguiba Hospital, Sfax, Tunisia
2 Laboratory of Pathological Anatomy, Habib Bourguiba Hospital, Sfax, Tunisia
| Date of Web Publication | 23-Feb-2023 |
Correspondence Address:
Rim Chaabouni
Department of Dermatology, Hedi Chaker Hospital, 3029 Sfax
Tunisia
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijd.ijd_585_21
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How to cite this article:
Chaabouni R, Bahloul E, Bahri I, Sellami K, Boudawara T, Turki H. Annular erythematous skin lesions in a 51-year-old man. Indian J Dermatol 2022;67:838 |
How to cite this URL:
Chaabouni R, Bahloul E, Bahri I, Sellami K, Boudawara T, Turki H. Annular erythematous skin lesions in a 51-year-old man. Indian J Dermatol [serial online] 2022 [cited 2023 Mar 23];67:838. Available from: https://www.e-ijd.org/text.asp?2022/67/6/838/370325 |
A 51-year-old man presented with an annular pruritic eruption of 3 months duration. He was otherwise healthy with an unremarkable medical history. He denied taking any medications.
Physical examination revealed annular and arciform erythematous non-scaly plaques with papular oedematous borders, showing centrifugal expansion and central healing, involving the neck, trunk and limbs [Figure 1]. Routine laboratory investigations including complete blood count, erythrocyte sedimentation rate, C-reactive protein and liver and renal function did not reveal any abnormality. | Figure 1: Annular and arciform erythematous non-scaly plaques involving the trunk (a + b), arms (c) and legs (d)
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 Histological Findings | |  |
Skin biopsy showed perivascular dermal inflammatory infiltration with numerous eosinophils. There were also some flame figures. There was no evidence of granulomatous changes or vasculitis [Figure 2]. Direct immunofluorescence was negative. | Figure 2: Dermal perivascular inflammatory infiltrate mainly composed of eosinophils with some flame figures. (Haematoxylin and eosin stain; original magnification ×200)
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| What is Your Diagnosis? | | |
Eosinophilic annular erythema (EAE).
| Clinical Course | | |
The patient was treated with oral hydroxychloroquine 200 mg twice daily. All lesions had completely cleared within 2 months without scarring. However, a recurrence was noted 2 years after discontinuation of treatment, which was successfully treated with hydroxychloroquine.
| Discussion | | |
EAE is a rare dermatosis characterized by recurrent annular erythematous plaques involving mainly the trunk and proximal extremities, with tissue eosinophilia.[1] The pathogenesis of EAE remains unknown, although it has been considered as the result of a hypersensitive reaction to an unidentified allergen. The condition has been associated with several systemic disorders such as autoimmune thyroid disease, chronic hepatitis virus C, chronic gastritis with Helicobacter pylori, diabetes mellitus, chronic kidney disease and internal malignancies.[2]
It remains unclear whether EAE represents a subtype of Wells' syndrome (WS) or a distinct entity. However, there are some clinical and histopathological differences between the two conditions. Clinically, WS manifests as well-defined erythematous painful cellulitis-type plaques, evolving, within a few weeks, to morphea-like lesions, although annular and figurate plaques have been reported in WS.[3] Blood eosinophilia, commonly noted in WS, is usually absent in EAE.[4] Histologically, WS is characterized by an interstitial infiltrate rich in eosinophil involving the dermis and subcutis and by the presence of flame figures with a granulomatous reaction. In contrast, EAE is characterized by the lack of flame figures and granulomatous inflammation. In addition, eosinophilic infiltrate is usually confined to the dermis. However, like in our case, flame figures have been reported in some cases of EAE. Furthermore, El-Khalawany et al.[3] had demonstrated that histopathological findings in EAE may differ depending on the timing of biopsy and that in well-developed lesions, the eosinophil infiltrate may extend into the subcutis, and flame figures may be observed. Both WS and EAE have a benign course and spontaneous resolution can occur. Systemic steroids are usually proposed as the first-line treatment in WS, while antimalarial drugs are considered the treatment of choice in EAE. However, high rates of recurrence were noted in the two conditions.[5]
In our case, the annular presentation of lesions, the absence of blood eosinophilia and the good response to hydroxychloroquine argue in favour of the diagnosis of EAE. However, the presence of flame figures may support the hypothesis that EAE is a clinical variant of WS characterized by an annular pattern and by a good response to antimalarial drugs.
| Learning Points | | |
- EAE is a rare recently described figurate dermatitis of unknown aetiology, characterized by recurrent annular erythematous plaques with tissue eosinophilia.
- EAE has been associated with several chronic diseases and malignant tumours.
- Histologically, in contrast to WS, EAE is characterized by a marked eosinophilic infiltrate which is confined to the dermis, with no granulomatous inflammation or flame figures. However, like in our case, flame figures have been reported in some cases of EAE.
- Antimalarials are the recommended first-line treatment for EAE. However, spontaneous remission is also reported.
- The relapse rate is high.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Thomas L, Fatah S, Nagarajan S, Natarajan S. Eosinophilic annular erythema: Successful response to ultraviolet B therapy. Clin Exp Dermatol 2015;40:883-6.  |
| 2. | Karataş Toğral A, Seçkin D. Eosinophilic annular erythema: A late but complete response to hydroxychloroquine. Australas J Dermatol 2017;58:228-30. |
| 3. | El-Khalawany M, Al-Mutairi N, Sultan M, Shaaban D. Eosinophilic annular erythema is a peculiar subtype in the spectrum of Wells syndrome: A multicentre long-term follow-up study: Eosinophilic annular erythema is a peculiar subtype in the spectrum of Wells syndrome. J Eur Acad Dermatol Venereol 2013;27:973-9. |
| 4. | Nakazato S, Fujita Y, Shinkuma S, Nomura T, Shimizu H. Eosinophilic annular erythema is clinically characterized by central pigmentation reflecting basal melanosis: A clinicopathological study of 10 cases. J Eur Acad Dermatol Venereol 2017;31:1916-23. |
| 5. | Rongioletti F, Fausti V, Kempf W, Rebora A, Parodi A. Eosinophilic annular erythema: An expression of the clinical and pathological polymorphism of Wells syndrome. J Am Acad Dermatol 2011;65:e135-7. |
[Figure 1], [Figure 2] |
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