eMedicine Specialties > Dermatology > Pediatric Diseases

Asymmetric Periflexural Exanthem of Childhood

Author: Stewart P Adams, MD, FRCPC, Clinical Assistant Professor, Department of Medicine, University of Calgary Faculty of Medicine
Coauthor(s): Patricia T Ting, MD, Staff Physician, Department of Medicine, University of Calgary
Contributor Information and Disclosures

Updated: Feb 16, 2007

Introduction

Background

In 1962, Brunner et al reported a "new papular erythema" in 75 children aged 6 months to 5 years. Later, in 1992, Bodemer and de Prost published a case series of 18 children and named the condition unilateral laterothoracic exanthem (ULE). In 1993, Taieb and colleagues suggested the term asymmetric periflexural exanthem of childhood (APEC) to replace ULE, as the latter did not fully depict the morphologic distribution of the skin lesions present in this condition. APEC is classified as a rare self-limited and spontaneously resolving exanthem with unknown etiology that occurs in children. To date, only 3 case presentations in adults have been documented.

Pathophysiology

The etiology of APEC is unknown. The patient's history (eg, age at presentation, multiple affected children in a family), lack of efficacy of broad-spectrum antibiotic treatment, serologic findings, and the tendency for presentation during spring and winter raise the possibility of a viral etiology. However, the evidence has been inconclusive, and clinicians have not been able to isolate a specific virus. Therefore, this hypothesis has never been confirmed.

APEC manifests as an exanthem with stereotypical morphology and distribution. Biopsy is rarely if ever performed, as the presentation of this condition is unique and resolves spontaneously without treatment or adverse sequelae.

Frequency

United States

APEC is a relatively rare condition that often appears in spring and winter months.

International

Approximately 300 cases have been reported in the literature. Case series of affected children have been documented internationally from the United States, Canada, and Europe.

Mortality/Morbidity

None is reported.

Race

APEC predominantly affects individuals from light-skinned ethnic groups.

Sex

APEC tends to affect females more frequently than males, with an estimated female-to-male ratio of 2:1.

Age

  • The average age of presentation is 2 years, though affected children may be aged 4 months to 10 years.
  • Four cases of APEC in adults have been reported in the literature.

Clinical

History

  • Most affected children are healthy and asymptomatic at presentation, with an unremarkable medical history.
  • Occasionally, patients may report a current and/or recent episode of upper respiratory tract infection, adenopathy/lymphadenopathy, fever, otitis media, or diarrhea.
  • In rare instances, other children in the family may also have APEC.
  • Mild pruritus is reported in approximately 50% of patients.

Physical

  • The primary (pathognomonic) lesion is a small erythematous papule with a surrounding pale halo. The general appearance of lesions includes a morbilliform, eczematous, and occasionally reticulated group of macules, papules, or coalescent plaques. These are occasionally accompanied with fine scaling.
  • At the initial onset, lesions are unilateral and usually begin near the axillae, lateral trunk, and upper inner arm or groin. During the course of the condition, lesions often progress bilaterally with an asymmetric predominance.
  • The 4 sequential stages of the lesions are as follows:
    • Eczematous, when initial lesions occur on the axillae and lateral chest wall
    • Coalescence, when lesions extend to the trunk and proximal extremities and are separated by areas of normal skin
    • Regression, when older lesions may develop a central dusky-gray center
    • Desquamation, when residual branlike scale appears and resolves with time
  • APEC lesions spare the face, palms, soles, and mucous membranes.
  • Lichenification is not usually observed.

Causes

The exact cause of this eruption is unknown, and no specific viral pathogens have been identified.

More on Asymmetric Periflexural Exanthem of Childhood

Overview: Asymmetric Periflexural Exanthem of Childhood
Differential Diagnoses & Workup: Asymmetric Periflexural Exanthem of Childhood
Treatment & Medication: Asymmetric Periflexural Exanthem of Childhood
Follow-up: Asymmetric Periflexural Exanthem of Childhood
Multimedia: Asymmetric Periflexural Exanthem of Childhood
References
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References

  1. Auvin S, Imiela A, Cuvellier JC, et al. Asymmetric periflexural exanthem of childhood in a child with axonal Guillain-Barre syndrome. Br J Dermatol. Feb 2004;150(2):396-7. [Medline].

  2. Bauza A, Redondo P, Fernandez J. Asymmetric periflexural exanthem in adults. Br J Dermatol. Jul 2000;143(1):224-6. [Medline].

  3. Bodemer C, de Prost Y. Unilateral laterothoracic exanthem in children: a new disease?. J Am Acad Dermatol. Nov 1992;27(5 Pt 1):693-6. [Medline].

  4. Brunner MJ, Rubin L, Dunlap F. A new papular erythema of childhood. Arch Dermatol. Apr 1962;85:539-40. [Medline].

  5. Chan PK, To KF, Zawar V, et al. Asymmetric periflexural exanthem in an adult. Clin Exp Dermatol. May 2004;29(3):320-1. [Medline].

  6. Corazza M, Virgili A. Asymmetric periflexural exanthem in an adult. Acta Derm Venereol. Jan 1997;77(1):79-80. [Medline].

  7. Coustou D, Leaute-Labreze C, Bioulac-Sage P, et al. Asymmetric periflexural exanthem of childhood: a clinical, pathologic, and epidemiologic prospective study. Arch Dermatol. Jul 1999;135(7):799-803. [Medline].

  8. Coustou D, Masquelier B, Lafon ME. Asymmetric periflexural exanthem of childhood: microbiologic case-control study. Pediatr Dermatol. May-Jun 2000;17(3):169-73. [Medline].

  9. Guimera-Martin-Neda F, Fagundo E, Rodriguez F, et al. Asymmetric periflexural exanthem of childhood: report of two cases with parvovirus B19. J Eur Acad Dermatol Venereol. Apr 2006;20(4):461-2. [Medline].

  10. Gutzmer R, Herbst RA, Kiehl P, et al. Unilateral laterothoracic exanthem (asymmetrical periflexural exanthem of childhood): report of an adult patient. J Am Acad Dermatol. Sep 1997;37(3 Pt 1):484-5. [Medline].

  11. Harangi F, Várszegi D, Szücs G. Asymmetric periflexural exanthem of childhood and viral examinations. Pediatr Dermatol. Jun 1995;12(2):112-5. [Medline].

  12. McCuaig CC, Russo P, Powell J, et al. Unilateral laterothoracic exanthem. A clinicopathologic study of forty-eight patients. J Am Acad Dermatol. Jun 1996;34(6):979-84. [Medline].

  13. Nahm WK, Paiva C, Golomb C, et al. Asymmetric periflexural exanthem of childhood: a case involving a 4-month-old infant. Pediatr Dermatol. Sep-Oct 2002;19(5):461-2. [Medline].

  14. Pauluzzi P, Festini G, Gelmetti C. Asymmetric periflexural exanthem of childhood in an adult patient with parvovirus B19. J Eur Acad Dermatol Venereol. Jul 2001;15(4):372-4. [Medline].

  15. Taieb A, Megraud F, Legrain V, et al. Asymmetric periflexural exanthem of childhood. J Am Acad Dermatol. Sep 1993;29(3):391-3. [Medline].

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Further Reading

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Keywords

unilateral laterothoracic exanthem of childhood, ULE, APEC, papular erythema

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Contributor Information and Disclosures

Author

Stewart P Adams, MD, FRCPC, Clinical Assistant Professor, Department of Medicine, University of Calgary Faculty of Medicine
Stewart P Adams, MD, FRCPC is a member of the following medical societies: American Academy of Dermatology, American Medical Association, and Canadian Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Patricia T Ting, MD, Staff Physician, Department of Medicine, University of Calgary
Patricia T Ting, MD is a member of the following medical societies: Alberta Medical Association and Canadian Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Timothy McCalmont, MD, Director, UCSF Dermatopathology Service, Professor of Clinical Pathology and Dermatology, Departments of Pathology and Dermatology, University of California at San Francisco
Timothy McCalmont, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, American Society of Dermatopathology, California Medical Association, College of American Pathologists, and United States and Canadian Academy of Pathology
Disclosure: Nothing to disclose.

Pharmacy Editor

David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Director, Division of Dermatology, Scott and White Clinic; Director Dermatology Residency Training Program, Scott and White Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: 3M Pharmaceutical Grant/research funds Other; Graceway Pharmaceuticals Grant/research funds Other

Managing Editor

Robert A Schwartz, MD, MPH, Professor and Head of Dermatology, Professor of Medicine, Professor of Pediatrics, Professor of Pathology, Professor of Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi
Disclosure: Nothing to disclose.

CME Editor

Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University
Catherine Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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