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Erythema Annulare Centrifugum: Differential Diagnoses & Workup

Author: Robert J Willard, MD, Dermatologist and Mohs Surgeon, Private Practice, Dermatology and Mohs Surgery Center, PC
Coauthor(s): Andrew D Montemarano, DO, Consulting Staff, The Skin Cancer Surgery Center
Contributor Information and Disclosures

Updated: Dec 14, 2009

Differential Diagnoses

Cutaneous T-Cell Lymphoma
Erythema Gyratum Repens
Granuloma Faciale
Lupus Erythematosus, Subacute Cutaneous

Other Problems to Be Considered

  • Annular urticaria
  • Benign lymphocytic infiltrate
  • Erythema migrans: These lesions are typically less numerous, less circinate in configuration, and often accompanied by a history of a tick bite (Ixodes scapularis).
  • Erythema gyratum repens: EAC can be distinguished from this condition by its slower rate of spread (weeks rather than days) and by its less bizarre configuration. Also, erythema gyratum repens is almost always associated with an underlying malignancy.
  • Erythema marginatum rheumaticum: This is a nonscaling gyrate erythema that by definition is found in association with rheumatic fever (10-18% of patients with rheumatic fever). The rate of spread is measurable in hours, and the skin infiltrate is neutrophilic as opposed to lymphohistiocytic.
  • Facial granuloma
  • Subacute cutaneous lupus erythematosus (annular variant): These lesions tend to coalesce and can be accompanied by central hypopigmentation and telangiectasias.

Workup

Laboratory Studies

  • Skin scrapings from lesional sites of erythema annulare centrifugum (EAC) should be analyzed after preparation in potassium hydroxide (KOH) to ascertain the presence or the absence of hyphae suggestive of tinea or candidiasis.
  • Lyme antibody titer is needed to exclude erythema migrans.
  • An antinuclear antibody test should be performed in the appropriate clinical setting. Systemic lupus erythematosus is in the differential diagnosis of EAC, and Sjögren syndrome has been reported in association with EAC.
  • A purified protein derivative (PPD) test and an anergy panel can be used to determine if an underlying M tuberculosis infection is present.
  • A complete blood count with differential can be used to determine a suspected underlying infection (neutrophilia with bacterial infection; eosinophilia with parasitic infection or hypereosinophilic syndrome).
  • If compatible with the clinical presentation of erythema annulare centrifugum, liver function studies may be useful because hyperbilirubinemia secondary to cholestasis and elevated transaminase levels secondary to hepatitis have been reported with EAC.
  • With an appropriate history of gastrointestinal complaints, a stool examination may be useful to search for ova and parasites (ascariasis has been reported with EAC).
  • For females, serum or urine beta-human chorionic gonadotropin testing may be indicated.

Imaging Studies

  • Chest radiography can be used to exclude pulmonary nodules or hilar adenopathy suggestive of tuberculosis, malignancy (primary or metastatic), sarcoidosis, or lymphoma, all of which have been associated with erythema annulare centrifugum (EAC).

Procedures

  • A skin punch biopsy may be performed on erythema annulare centrifugum (EAC) lesions.

Histologic Findings

A biopsy is helpful in confirming a diagnosis of EAC. Two histologic subtypes exist: deep and superficial. In the classic or deep type, an intense, superficial and deep lymphocytic or lymphohistiocytic perivascular infiltrate in a coat-sleeve fashion is observed in the middle and lower dermis. No epidermal changes are observed. Clinically, these erythema annulare centrifugum (EAC) lesions have indurated borders and are nonscaly and nonpruritic.

In the superficial type of erythema annulare centrifugum, a more nonspecific perivascular lymphohistiocytic infiltrate about the superficial dermal vessels and edema of the papillary dermis is present. The epidermal changes of parakeratosis and spongiosis may be present. Clinically, these lesions have a scale, may be pruritic, and may have vesiculations.

More on Erythema Annulare Centrifugum

Overview: Erythema Annulare Centrifugum
Differential Diagnoses & Workup: Erythema Annulare Centrifugum
Treatment & Medication: Erythema Annulare Centrifugum
Follow-up: Erythema Annulare Centrifugum
Multimedia: Erythema Annulare Centrifugum
References
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References

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Further Reading

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Keywords

erythema annulare centrifugum, EAC, erythema gyratum perstans, erythema exudativum perstans, erythema marginatum perstans, erythema perstans, erythema figuratum perstans, erythema microgyratum perstans, erythema simplex gyratum

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Contributor Information and Disclosures

Author

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 Micrographic Surgery and Cutaneous Oncology, and American Society for Dermatologic Surgery
Disclosure: Nothing to disclose.

Coauthor(s)

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 Micrographic Surgery and Cutaneous Oncology, American Society for Dermatologic Surgery, and MedChi
Disclosure: Nothing to disclose.

Medical Editor

Evan R Farmer, MD, Clinical Professor of Pathology and Dermatology, Department of Pathology, Virginia Commonwealth University School of Medicine
Evan R Farmer, MD is a member of the following medical societies: American Academy of Dermatology, American Dermatological Association, American Medical Association, American Society of Dermatopathology, and International Society of Dermatology
Disclosure: Nothing to disclose.

Pharmacy Editor

Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center
Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Warren R Heymann, MD, Head, Division of Dermatology, Professor, Department of Internal Medicine, University of Medicine and Dentistry of New Jersey
Warren R Heymann, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

CME Editor

Joel M Gelfand, MD, MSCE, Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania
Joel M Gelfand, MD, MSCE is a member of the following medical societies: Society for Investigative Dermatology
Disclosure: AMGEN Consulting fee Consulting; AMGEN Grant/research funds Investigator; Genentech Grant/research funds investigator; Centocor Consulting fee Consulting; Abbott Grant/research funds investigator; Abbott Consulting fee Consulting; Novartis  investigator; Pfizer Grant/research funds investigator; Celgene Consulting fee DMC Chair; NIAMS and NHLBI Grant/research funds investigator

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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