eMedicine Specialties > Dermatology > Reactive & Inflammatory Dermatoses

Erythema Annulare Centrifugum: Treatment & Medication

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: Aug 13, 2008

Treatment

Medical Care

EAC is usually self-limited. Topical steroids usually cause involution of the treated lesions, but they do not prevent the occurrence of new lesions or recurrence of the eruption. Systemic or injection steroid therapy is effective, but the eruption returns once these drugs are withdrawn. As previously mentioned, several cases of EAC have resolved once the underlying diseases were treated. Therefore, a search for and treatment of the underlying disorder is the primary therapy. However, an exhaustive workup for occult malignancy is not warranted because the relationship between EAC and cancer is not consistent. Remember that no cause is found in most cases.

The patient's medications should be reviewed with particular attention to and discontinuation of the drugs known to be associated with EAC. Recent additions to the patient's drug regimen should be eliminated, and the patient should be observed for signs of resolution.

In a case of EAC associated with hypereosinophilic syndrome, the eruption resolved after treatment with ketoconazole, dapsone, and trimethoprim-sulfamethoxazole.5

A case of EAC of infantile onset in the French literature documents dramatic improvement with interferon alpha therapy.25

Case reports have documented success in the treatment of EAC with drugs previously unreported to be useful for EAC.

  • Hyaluronic acid: 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 improvement of his osteoarthritis and resolution of his EAC.24
  • Calcipotriol: A case of EAC of 3 years' duration in a 73-year-old woman responded to calcipotriol after the patient did not respond to topical and systemic corticosteroids, antifungals, and psoralen with UV-A therapy. The eruption cleared completely after 3 months of treatment with calcipotriol.26 One report also described EAC responding to combination calcipotriol and narrow-band UVB.27
  • Metronidazole: A 38-year-old man with a 2-year history of EAC for which an underlying cause could not be found and that failed to respond to systemic antibiotics (ie, ciprofloxacin, clarithromycin), antifungal agents (ie, itraconazole, terbinafine), and topical calcipotriol did respond to oral metronidazole. The drug had been given to treat papulopustular rosacea. His EAC was coincidentally found to resolve, as did his rosacea, after 1 month of therapy. No recurrence of EAC was noted after 1 year of follow-up. A possible causal relationship between rosacea and EAC was postulated in the report.28
  • Etanercept: A 57-year-old man with erythema annulare centrifugum, unsuccessfully treated previously with narrow-band UVB, topical steroids, and methotrexate, responded with complete resolution of his eruption after 4 weeks of therapy with etanercept at 25 mg SQ twice weekly. The erythema annulare centrifugum eruption recurred upon cessation of etanercept therapy and resolved again with resumption of therapy.2

Consultations

  • Consult a dermatologist for diagnosis and evaluation of the underlying cause of EAC.
  • Consult an internal medicine specialist for evaluation of the underlying cause of EAC.

Medication

The goals of pharmacotherapy for erythema annulare centrifugum (EAC) are to reduce morbidity and to prevent complications.

Corticosteroids

Topical agents are used for treatment of inflammatory lesions of EAC and for symptomatic relief of pruritus. A short course of systemic steroid therapy may be considered for very symptomatic cases of EAC (eg, severe pruritus).


Fluocinonide (Fluonex, Lidex)

A group II topical steroid. The anti-inflammatory potency group is determined by the degree of vasoconstriction induced by the drug in the small vessels of the upper dermis (I is most potent; VII is least potent). Use drug in all involved areas except those where the skin is particularly thin (eg, face, scrotum, axilla, flexural areas).

Adult

0.05% cream applied to affected areas bid until lesions resolve or for 4 wk; not to exceed 50-60 g/wk

Pediatric

Not recommended

Documented hypersensitivity; herpes simplex infection; fungal, viral, or tubercular skin lesions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Children may be more susceptible to topical steroid-induced adrenal suppression and Cushing syndrome than adults because of their greater skin surface area to body weight ratio; skin atrophy occurs with prolonged use (4-8 wk)


Hydrocortisone valerate (Westcort)

Group V topical steroid. The anti-inflammatory potency group is determined by the degree of vasoconstriction induced by the drug in the small vessels of the upper dermis (I is most potent; VII is least potent). This topical corticosteroid should be used on involved areas of the skin that are particularly thin, such as the face, axilla, scrotum, and flexural areas.

Adult

0.2% cream applied to affected areas bid until resolution occurs or for 4 wk

Pediatric

Apply as in adults; may need to taper applications to minimize risk of adrenal suppression

Corticosteroid clearance may decrease with estrogens; may increase digitalis toxicity secondary to hypokalemia

Documented hypersensitivity; viral, fungal, or tubercular skin infections

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hyperthyroidism, osteoporosis, peptic ulcer, cirrhosis, nonspecific ulcerative colitis, diabetes, and myasthenia gravis; children may be more susceptible to topical steroid-induced adrenal suppression and Cushing syndrome than adults because of their greater skin surface area to body weight ratio; skin atrophy occurs with prolonged use (6-8 wk)


Prednisone (Deltasone)

Immunosuppressant for treatment of autoimmune disorders. May decrease inflammation by reversing increased capillary permeability and suppressing PMN activity. Stabilizes lysosomal membranes and also suppresses lymphocyte and antibody production.

Adult

0.5-1 mg/kg/d PO every am for 7-21 d; taper as condition improves; single morning dose is safer for long-term use, but divided doses have more anti-inflammatory effect

Pediatric

Not established

Coadministration with estrogens may decrease clearance; when used with digoxin, digitalis toxicity secondary to hypokalemia may increase; phenobarbital, phenytoin, and rifampin may increase the metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics; coadministration with ritonavir may significantly increase prednisone serum concentrations; concomitant therapy with montelukast may result in severe peripheral edema; clarithromycin may increase risk of psychotic symptoms

Documented hypersensitivity; viral, fungal, tubercular skin, or connective tissue infections; peptic ulcer disease; hepatic dysfunction; GI tract disease; administration of live virus vaccines to patients receiving immunosuppressive corticosteroids

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

May unmask hypertension or diabetes or exacerbate peptic ulcer disease and tuberculosis; long-term sequelae associated with long-term steroid use include osteoporosis, cataracts, and pituitary-hypothalamic axis suppression; with high doses, patients may develop a steroid psychosis and are at increased risk of infections, particularly when oral steroids are used in conjunction with other immunosuppressants; frequently monitor patient's blood sugar level, blood pressure, and weight; monitor for Cushing syndrome

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

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

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

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

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

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

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

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

  8. 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. Aug 2002;47(2):311-3. [Medline].

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

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

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

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

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

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

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

  16. 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. Dec 2005;153(6):1241-3. [Medline].

  17. 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. Dec 2006;45(12):1423-5. [Medline].

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

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

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

  21. 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. Sep 1975;93(3):341-5. [Medline].

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

  23. 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. Jan 1993;32(1):59-61. [Medline].

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

  25. 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].

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

  27. 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. Feb 2007;58(2):146-8. [Medline].

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

  29. Janss G, Schmidt K, Gattuso P, Massa M, Welykyj S. An intensive care unit nurse with a recurring annular lesion. Erythema annulare centrifugum (EAC). Arch Dermatol. Jul 1992;128(7):977, 980. [Medline].

  30. Lazar P. Cancer, erythema annulare centrifugum, autoimmunity. Arch Dermatol. 1963;87:246-51.

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Further Reading

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Keywords

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

Medical Editor

Evan R Farmer, MD, Professor of Dermatology, Johns Hopkins University School of Medicine, Clinical Professor of Pathology, Virginia Commonwealth University School of Medicine; Consulting Staff, Department of Dermatology, Johns Hopkins Hospital, VCU Health Services
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 None; Genentech Consulting fee Consulting; Centocor Consulting fee Consulting; Centocor Grant/research funds None; Covance Consulting fee Consulting; Shire  Consulting

Chief Editor

William D James, MD, Paul R Gross Professor of Dermatology, University of Pennsylvania School of Medicine; Vice-Chair, Program Director, Department of Dermatology, University of Pennsylvania Health System
William D James, MD is a member of the following medical societies: American Academy of Dermatology and Society for Investigative Dermatology
Disclosure: elsevier Royalty Other; american college of physicians Honoraria Other

 
 
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