Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Erythema Annulare Centrifugum Clinical Presentation

  • Author: Marisel Peralta-Abejo, MD, DPDS; Chief Editor: William D James, MD  more...
 
Updated: Apr 28, 2016
 

History

Usually, patients with erythema annulare centrifugum (EAC) present 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).[10]

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 erythema annulare centrifugum exist (most commonly antimalarials, cimetidine, spironolactone, gold, salicylates, piroxicam, penicillin, and amitriptyline).

One case report[11] 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.[12] The eruption resolved 1 month after delivery, without recurrence after 8 months of follow-up.

Next

Physical

Pertinent physical findings of erythema annulare centrifugum (EAC) are usually limited to the skin, but a full physical examination should be conducted to assess for an underlying systemic process.

Skin findings are as follows:

  • 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, as shown in the images below. 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. Note the images below.
    Arcuate lesions of erythema annulare centrifugum d Arcuate lesions of erythema annulare centrifugum demonstrate minimal scale.
    Superficial erythema annulare centrifugum demonstr Superficial erythema annulare centrifugum demonstrates a central clearing and trailing scale behind an advancing, annular, erythematous border.
  • 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.

Other findings are as follows:

  • 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. [4]
  • Lungs: Tuberculosis, [13] lymphoma, sarcoidosis, and malignant bronchial carcinoid have been associated with EAC, warranting examination of the lungs.
  • Abdomen: Appendicitis, [6] lymphoma (with associated splenomegaly), and liver disease [3] (eg, cholelithiasis, hepatitis), and pregnancy have been reported with EAC. The abdomen should be examined for tenderness, masses, or hepatosplenomegaly.
Previous
Next

Causes

Most commonly, no cause is found for the erythema annulare centrifugum (EAC).[14] 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

Infection-related causes include the following:

  • 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. [15] 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 [16] ; EAC resolved after treatment with piperazine and thiabendazole. Also, EAC has been reported in association with Phthirus pubis infestation. [17]
  • Viruses: EAC has been reported in association with Epstein-Barr virus (EBV) in an infant [18] 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." [19] In 2006, erythema annulare centrifugum (EAC) was reported in an HIV-positive patient. [20]

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. Note the following drugs that have been associated with EAC:

  • Amitriptyline [21]
  • Azacitidine [22]
  • Chloroquine
  • Cimetidine
  • Estrogen
  • Etizolam [23]
  • Finasteride
  • Hydrochlorothiazide
  • Hydroxychloroquine [24]
  • Gold sodium thiomalate
  • Pegylated interferon alfa-2a plus ribavirin combination therapy [25]
  • Penicillin
  • Piroxicam
  • Rituximab [26]
  • Salicylates
  • Ustekinumab [27]

Neoplasms

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. Note the following:

  • Squamous cell carcinoma (in a sebaceous cyst)
  • Nasopharyngeal carcinoma
  • Acute myelogenous leukemia
  • Peritoneal carcinomatosis
  • Primary bronchial carcinoid [28]
  • Hodgkin lymphoma [29, 30]
  • Chronic lymphocytic leukemia
  • Multiple myeloma
  • Prostate cancer
  • Malignant histiocytosis
  • Ovarian carcinoma (mucinous)
  • Breast cancer [31]

Other causes

Other reported causes vary and include the following:

  • Foods: Blue cheese and tomatoes have been reported to cause EAC
  • Recurrent acute appendicitis: The lesions of EAC resolved 1 month after appendectomy. [6]
  • Cholestatic liver disease (secondary to choledocholithiasis): EAC resolved within 3 days of removal of the stone. [3]
  • Graves disease: The patient's eruption disappeared 2 weeks after treatment with I-131 for thyroid ablation. [4]
  • 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. [11]
  • 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. [5]
  • 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. [32]
  • Stress: One report describes stress as an inciting factor in one case of EAC. The patient experienced EAC at the onset of stressful life periods, which abated without treatment upon discontinuation of the stressful period in the patient’s life. [33]
  • Pregnancy: One case report describes the onset of EAC during pregnancy, with resolution occurring shortly before delivery. [34]
Previous
 
 
Contributor Information and Disclosures
Author

Marisel Peralta-Abejo, MD, DPDS Dermatology Consultant, Bulacan Primehealth Multi-Specialty Clinic, Meycauayan Doctors Hospital, and Valenzuela Citicare Medical Center

Marisel Peralta-Abejo, MD, DPDS is a member of the following medical societies: Philippine Dermatological Society

Disclosure: Nothing to disclose.

Coauthor(s)

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael J Wells, MD, FAAD Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Michael J Wells, MD, FAAD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Texas Medical Association

Disclosure: Nothing to disclose.

Warren R Heymann, MD Head, Division of Dermatology, Professor, Department of Internal Medicine, Rutgers New Jersey Medical School

Warren R Heymann, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Robert J Willard, MD Dermatologist and Mohs Surgeon, Private Practice, Dermatology and Mohs Surgery Center, PC

Robert J Willard, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery

Disclosure: Nothing to disclose.

Andrew D Montemarano, DO Consulting Staff, The Skin Cancer Surgery Center

Andrew D Montemarano, DO is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery, MedChi The Maryland State Medical Society

Disclosure: Nothing to disclose.

References
  1. Bressler GS, Jones RE Jr. Erythema annulare centrifugum. J Am Acad Dermatol. 1981 May. 4(5):597-602. [Medline].

  2. Minni J, Sarro R. A novel therapeutic approach to erythema annulare centrifugum. J Am Acad Dermatol. 2006 Mar. 54(3 Suppl 2):S134-5. [Medline].

  3. Tsuji T, Kadoya A. Erythema annulare centrifugum associated with liver disease. Arch Dermatol. 1986 Nov. 122(11):1239-40. [Medline].

  4. Braunstein BL. Erythema annulare centrifugum and Graves' disease. Arch Dermatol. 1982 Sep. 118(9):623. [Medline].

  5. Shelley WB, Shelley ED. Erythema annulare centrifugum as the presenting sign of the hypereosinophilic syndrome: observations on therapy. Cutis. 1985 Jan. 35(1):53-5. [Medline].

  6. Sack DM, Carle G, Shama SK. Recurrent acute appendicitis with erythema annulare centrifugum. Arch Intern Med. 1984 Oct. 144(10):2090-2. [Medline].

  7. Ohmori S, Sugita K, Ikenouci-Sugita A, Nakamura M. Erythema annulare centrifugum associated with herpes zoster. J UOEH. 2012 Sep 1. 34(3):225-9. [Medline].

  8. Mahood JM. Erythema annulare centrifugum: a review of 24 cases with special reference to its association with underlying disease. Clin Exp Dermatol. 1983 Jul. 8(4):383-7. [Medline].

  9. Mandel VD, Ferrari B, Manfredini M, Giusti F, Pellacani G. Annually recurring erythema annulare centrifugum: a case report. J Med Case Rep. 2015 Oct 22. 9:236. [Medline].

  10. Carlesimo M, Fidanza L, Mari E, et al. Erythema annulare centrifugum associated with mantle b-cell non-Hodgkin's lymphoma. Acta Derm Venereol. 2009. 89(3):319-20. [Medline].

  11. Halevy S, Cohen AD, Lunenfeld E, Grossman N. Autoimmune progesterone dermatitis manifested as erythema annulare centrifugum: Confirmation of progesterone sensitivity by in vitro interferon-gamma release. J Am Acad Dermatol. 2002 Aug. 47(2):311-3. [Medline].

  12. Rosina P, D'Onghia FS, Barba A. Erythema annulare centrifugum and pregnancy. Int J Dermatol. 2002 Aug. 41(8):516-7. [Medline].

  13. Burkhart CG. Erythema annulare centrifugum. A case due to tuberculosis. Int J Dermatol. 1982 Nov. 21(9):538-9. [Medline].

  14. White JW Jr. Gyrate erythema. Dermatol Clin. 1985 Jan. 3(1):129-39. [Medline].

  15. Borbujo J, de Miguel C, Lopez A, de Lucas R, Casado M. Erythema annulare centrifugum and Escherichia coli urinary infection. Lancet. 1996 Mar 30. 347(9005):897-8. [Medline].

  16. Hendricks AA, Lu C, Elfenbein GJ, Hussain R. Erythema annulare centrifugum associated with ascariasis. Arch Dermatol. 1981 Sep. 117(9):582-5. [Medline].

  17. Bessis D, Chraibi H, Guillot B, Guilhou JJ. Erythema annulare centrifugum induced by generalized Phthirus pubis infestation. Br J Dermatol. 2003 Dec. 149(6):1291. [Medline].

  18. Hammar H. Erythema annulare centrifugum coincident with Epstein-Barr virus infection in an infant. Acta Paediatr Scand. 1974 Sep. 63(5):788-92. [Medline].

  19. Lee HW, Lee DK, Rhee DY, Chang SE, Choi JH, Moon KC, et al. Erythema annulare centrifugum following herpes zoster infection: Wolf's isotopic response?. Br J Dermatol. 2005 Dec. 153(6):1241-3. [Medline].

  20. González-Vela MC, González-López MA, Val-Bernal JF, Echevarría S, Arce FP, Fernández-Llaca H. Erythema annulare centrifugum in a HIV-positive patient. Int J Dermatol. 2006 Dec. 45(12):1423-5. [Medline].

  21. García-Doval I, Peteiro C, Toribio J. Amitriptyline-induced erythema annulare centrifugum. Cutis. 1999 Jan. 63(1):35-6. [Medline].

  22. Turan Erkek E, Kalayoğlu Beşışık S. An Unexpected Innocent Complication Associated with Azacitidine Treatment of Myelodysplastic Syndrome: Erythema Annulare Centrifugum. Turk J Haematol. 2016 Mar 5. 33 (1):81-82. [Medline].

  23. Kuroda K, Yabunami H, Hisanaga Y. Etizolam-induced superficial erythema annulare centrifugum. Clin Exp Dermatol. 2002 Jan. 27(1):34-6. [Medline].

  24. Hudson LD. Erythema annulare centrifugum: an unusual case due to hydroxychloroquine sulfate. Cutis. 1985 Aug. 36(2):129-30. [Medline].

  25. Gönül M, Külcü Çakmak S, Ozcan N, Deniz Oguz I, Ozhamam E. Erythema annulare centrifugum due to pegylated interferon-a-2a plus ribavirin combination therapy in a patient with chronic hepatitis C virus infection. J Cutan Med Surg. 2014 Jan-Feb. 18(1):65-8. [Medline].

  26. Mendes-Bastos P, Coelho-Macias V, Moraes-Fontes MF, Milheiro A, Rodrigues AM, Cardoso J. Erythema annulare centrifugum during rituximab treatment for autoimmune haemolytic anaemia. J Eur Acad Dermatol Venereol. 2014 Aug. 28(8):1125-7. [Medline].

  27. Chou WT, Tsai TF. Recurrent erythema annulare centrifugum during ustekinumab treatment in a psoriatic patient. Acta Derm Venereol. 2013 Mar 27. 93(2):208-9. [Medline].

  28. Everall JD, Dowd PM, Ardalan B. Unusual cutaneous associations of a malignant carcinoid tumour of the bronchus--erythema annulare centrifugum and white banding of the toe nails. Br J Dermatol. 1975 Sep. 93(3):341-5. [Medline].

  29. Leimert JT, Corder MP, Skibba CA, Gingrich RD. Erythema annulare centrifugum and Hodgkin's disease: association with disease activity. Arch Intern Med. 1979 Apr. 139(4):486-7. [Medline].

  30. Yaniv R, Shpielberg O, Shpiro D, Feinstein A, Ben-Bassat I. Erythema annulare centrifugum as the presenting sign of Hodgkin's disease. Int J Dermatol. 1993 Jan. 32(1):59-61. [Medline].

  31. Panasiti V, Devirgiliis V, Curzio M, Rossi M, Roberti V, Bottoni U, et al. Erythema annulare centrifugum as the presenting sign of breast carcinoma. J Eur Acad Dermatol Venereol. 2009 Mar. 23(3):318-20. [Medline].

  32. Ioannidou D, Krasagakis K, Stefanidou M, Tosca A. Erythema annulare centrifugum and osteoarthritis treated with hyaluronic acid. Clin Exp Dermatol. 2002 Nov. 27(8):720-2. [Medline].

  33. Ibrahim SF, Pryor J, Tausk FA. Stress-induced erythema annulare centrifugum. Dermatol Online J. 2009 Apr 15. 15(4):15. [Medline].

  34. Dogan G. Pregnancy as a possible etiologic factor in erythema annulare centrifugum. Am J Clin Dermatol. 2009. 10(1):33-5. [Medline].

  35. Cotterman C, Eckert L, Ackerman L. Syphilis mimicking tinea imbricata and erythema annulare centrifugum in an immunocompromised patient. J Am Acad Dermatol. 2009 Jul. 61(1):165-7. [Medline].

  36. Chodkiewicz HM, Cohen PR. Paraneoplastic erythema annulare centrifugum eruption: PEACE. Am J Clin Dermatol. 2012 Aug 1. 13(4):239-46. [Medline].

  37. Guillet MH, Dorval JC, Larrégue M, Guillet G. [Darier's erythema annulare centrifugum of neonatal onset with a 15 years' follow-up. Efficacy of interferon and role of cytokines]. Ann Dermatol Venereol. 1995. 122(6-7):422-6. [Medline].

  38. Gniadecki R. Calcipotriol for erythema annulare centrifugum. Br J Dermatol. 2002 Feb. 146(2):317-9. [Medline].

  39. Reuter J, Braun-Falco M, Termeer C, Bruckner-Tuderman L. [Erythema annulare centrifugum Darier. Successful therapy with topical calcitriol and 311 nm-ultraviolet B narrow band phototherapy]. Hautarzt. 2007 Feb. 58(2):146-8. [Medline].

  40. De Aloe G, Rubegni P, Risulo M, Sbano P, Poggiali S, Fimiani M. Erythema annulare centrifugum successfully treated with metronidazole. Clin Exp Dermatol. 2005 Sep. 30(5):583-4. [Medline].

  41. Chuang FC, Lin SH, Wu WM. Erythromycin as a Safe and Effective Treatment Option for Erythema Annulare Centrifugum. Indian J Dermatol. 2015 Sep-Oct. 60 (5):519. [Medline].

 
Previous
Next
 
Arcuate lesions of erythema annulare centrifugum demonstrate minimal scale.
Superficial erythema annulare centrifugum demonstrates a central clearing and trailing scale behind an advancing, annular, erythematous border.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.