Acrodermatitis Chronica Atrophicans Treatment & Management

Updated: Apr 22, 2019
  • Author: Robert A Schwartz, MD, MPH; Chief Editor: Dirk M Elston, MD  more...
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Treatment

Approach Considerations

The choice of treatment for acrodermatitis chronica atrophicans (ACA) depends on the coexistence of other signs or symptoms of Lyme borreliosis. One should also take into account the results of serologic tests. If not treated early, ACA can be associated with joint manifestations and persistent finger deformities.

Appropriate consultations (ie, neurologist, ophthalmologist, rheumatologist, cardiologist) should be sought if extracutaneous signs and symptoms are present. ACA patients without concurrent extracutaneous disease do not require hospitalization.

The US Food and Drug Administration (FDA) approved a vaccine against Lyme borreliosis for distribution in the United States in January 1999, but it is not currently in general use. At present, for European countries, a recombined vaccine is being prepared from the surface lipoprotein A (OspA) made from prevalent strains of B afzelii and B garinii.

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Pharmacologic Therapy

If extracutaneous Lyme borreliosis signs are absent and the level of specific antibodies is low, the authors usually recommend oral doxycycline or oral amoxicillin administered over a period of 3 weeks.

If organic or systemic physical or laboratory signs of Lyme borreliosis are present or if the antibody titer is high, appropriate treatment should be initiated, typically with ceftriaxone or cefotaxime or aqueous penicillin G given intravenously (IV) for 21-28 days. In a 2018 study, 5 of 7 patients had acrodermatitis chronica atrophicans resolve completely with ceftriaxone therapy. [14]

The possibility of another concurrent infection (eg, babesiosis, ehrlichiosis, or tick-borne encephalitis) must be kept in mind. About 10% of patients with Lyme disease in southern New England are coinfected with babesiosis, and about the same percentage in parts of the Midwestern United States have human granulocytic ehrlichiosis (HGE). Unlike ehrlichiosis, which is usually a short-lived infection, babesiosis can be persistent and may coexist with ACA.

Patients in the early phase of ACA should be assured that resolution of symptoms may occur gradually over a period of several weeks or months after treatment (see the images below); patients treated in the atrophic phase should be informed that although disease progression can be stopped, the symptoms may be only partially reversible.

After 30 days of treatment with ceftriaxone. After 30 days of treatment with ceftriaxone.
The same patient after treatment. The same patient after treatment.
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Long-Term Monitoring

Initially, follow-up care should be performed every 3-6 months; later, it may be performed once a year. Physical examination for signs and symptoms of cutaneous and extracutaneous manifestations of Lyme borreliosis is important. In most ACA patients who have received antibiotic therapy, quantitative serologic tests show IgG antibody titers that either do not change or decline only to a certain extent.

Despite the persistence of IgG antibody response in late Lyme borreliosis (serologic scar), similar to that observed in syphilis cases, the authors do serologic follow-up testing according to the recommendation for late syphilis. A sudden increase in antibody titer can point to the activation of infection and precede a clinical recurrence of the disease.

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