Eosinophilic annular erythema: A subset of Wells' syndrome or a distinct entity?

The role of eosinophils in the differential diagnosis of inflammatory skin diseases

Eosinophils are known to be present in inflammatory skin diseases, but their diagnostic utility is not well established. Upon review of the published status of lesional eosinophils, several categories were identified. 1) Lesional eosinophils highly characteristic such that, in their absence, the pathologist may question the diagnosis. These include arthropod bite reactions and scabies, urticarial dermatitis, and other eosinophilic dermatoses. 2) Lesional eosinophils rare or absent, such that, in their presence, the pathologist may question the diagnosis. These include pityriasis lichenoides, graft versus host disease, and connective tissue disorders. 3) Lesional eosinophils variable and, while in some cases expected, are not required for diagnosis. These include drug reactions, atopic dermatitis and allergic contact dermatitis. 4) Lesional eosinophils variable and not expected but may be seen to a limited extent. These include lichen planus and psoriasis.

Annular Erythemas and Purpuras

Annular dermatoses are a heterogeneous and extremely diverse group of skin diseases, which share in common annular, ring-like patterns with centrifugal spreading. Numerous skin diseases can sometimes display annular lesions, but some specific skin conditions are originally annular. We take the opportunity to review here mainly the causes of primary annular erythemas and their differential diagnoses, but also the rare causes of annular purpuras.

Eosinophilic Annular Erythema: A New Entity of Eosinophilic Dermatosis

Eosinophilic annular erythema (EAE) is a rare dermatosis. Its relationship with Wells syndrome (WS) is debated. We report a case treated with hydroxychloroquine.

 A 31-year-old patient presented with a mildly pruritic rash that had been evolving by flares for two weeks. Clinical examination revealed inflammatory erythematous-annular plaques on the trunk and limbs. The blood count was normal. Skin histology showed an eosinophilic-rich inflammatory infiltrate. After local steroid treatment, the patient was treated with oral steroids with a momentary improvement. The course with new relapses is treated by synthetic antimalarial drugs with the complete disappearance of the lesions at a six-month follow-up.

Although some authors consider EAE to be a variant of WS, we believe that there are subtle differences that differentiate them despite their clinical similarity.

Treatment of Eosinophilic Annular Erythema: Retrospective multicenter study and literature review

BACKGROUND

Eosinophilic annular erythema (EAE) is a rare eosinophil-related skin disease which typically manifests with annular erythematous plaques and severe pruritus. Besides the diagnosis, the treatment of EAE is challenging since relevant published data are sparse.

METHODS

The aim of this study was to assess the underlying diseases, treatments and outcomes of patients with EAE. To this end, we conducted a retrospective multicenter study and a systematic review of the MEDLINE database.

RESULTS

We included 18 patients with EAE followed in 8 centers. The MEDLINE database search yielded 37 relevant publications reporting 55 cases of EAE with 106 treatment sequences. The most common and efficient treatments included topical or systemic corticosteroids, hydroxychloroquine and dapsone. In refractory patients, a combination of systemic corticosteroids with hydroxychloroquine was associated with 88% of complete clinical response.

DISCUSSION

To improve the management of EAE patients, we discuss the following treatment strategy: in topical steroid-resistant patients, hydroxychloroquine can be given as first-line systemic treatment. Dapsone, hydroxychloroquine or systemic corticosteroids are second-line options to consider. Last, monoclonal antibodies or JAK inhibitors targeting type 2 inflammation could represent promising last-resort options in refractory patients.

Mepolizumab Therapy for Recalcitrant Eosinophilic Annular Erythema in an Adult: A Case Report and Review of Treatment Options

Eosinophilic annular erythema (EAE) is a rare condition with a chronic relapsing and remitting course, characterized by the presence of annular or polycyclic erythematous and plaque lesions and prominent tissue eosinophilia on histopathology. There is an ongoing discussion on whether EAE is a subset of Wells syndrome (eosinophilic cellulitis) or a separate entity. To date, few cases of EAE have been reported in the literature; of these, about 40 cases were in adults and fewer than ten cases were in children. Given the rarity of this condition, there are no clear recommendations for its management. Systemic corticosteroids and antimalarials are the most commonly used medications used to treat EAE, but many cases have been reported in the literature that are resistant to treatment with these medications. Here, we present a 65-year-old female with EAE refractory to numerous systemic therapies (corticosteroids, hydroxychloroquine, dapsone, doxycycline, methotrexate) who showed a good response to mepolizumab, a humanized monoclonal antibody that blocks interleukin-5. To the best of our knowledge, this is the first reported case of mepolizumab therapy in a patient with EAE. We also review other treatment strategies that have been used to manage this condition to date. Targeting cytokines crucial for the functioning of eosinophils may be a novel direction in the management of EAE, but prospective, double-blinded and placebo-controlled studies are needed to provide further evidence.

Two cases of wells syndrome with marked swelling in the hands

Wells syndrome or eosinophilic cellulitis is an idiopathic inflammatory dermatitis characterized by a benign but recurrent evolution. It often causes edematous urticarial plaques on the extremities. Herein, we report two rare cases of Wells syndrome with marked swelling in the hands. Both cases exhibited various clinical features. Case 1 was Wells syndrome with collagen disease-like sclerotic edema in the fingers and annular erythema on the trunk. Case 2 was Wells syndrome with diffuse plate-like hardening of the forearm mimicking cellulitis, which required fasciotomy due to suspected compartment syndrome at the emergency room. Wells syndrome should be included in the differential diagnosis of patients presenting with marked diffuse swelling in the hands.

Eosinophilic annular erythema treated with dupilumab

Eosinophilic annular erythema is a rare, benign, recurrent condition characterized by annular skin lesions, tissue eosinophilia, and resistance to a variety of treatments. There are fewer than 30 cases reported in the English literature, 7 of which are in children. We present a case of recurrent eosinophilic annular erythema in an adolescent that was successfully treated with dupilumab, an interleukin-4 receptor alpha antagonist.

Eosinophilic annular erythema in adults: report of two cases and review of the literature

We herein report two cases of eosinophilic annular erythema in adults, which is rare. In both patients, lesions developed rapidly in few days and were located mainly on the trunk, buttocks, and extremities. Diagnosis was histopathological, with typical features including acute dermal inflammatory infiltrate with abundant eosinophils. One of the patients recurred after treatment on three occasions and finally cured spontaneously. The second patient recurred once and was then successfully treated with topical clobetasol. Clinical and histopathological features of eosinophilic annular erythema in adults have rarely been reported. A review of the literature and discussion of relationship with Wells syndrome are also included.

Wells-Syndrom

Das Wells-Syndrom, auch als eosinophile Zellulitis bezeichnet, ist eine seltene, sporadisch auftretende eosinophile Dermatose mit polymorphem klinischem Bild. Als typisch gelten entzündliche Erytheme oder Plaques an den Extremitäten, die initial als Erysipel imponieren können, unter antimikrobieller Behandlung aber persistieren. Die eosinophile Zellulitis ist eine Ausschlussdiagnose, die in Zusammenschau von klinischem Befund und charakteristischem histologischem Bild (Flammenfiguren) nur im Verlauf gestellt werden kann. Mit einer Vielzahl möglicher Triggerfaktoren ist die Ätiologie nicht geklärt. Die Beteiligung abnormer Th2-Zellen, des Zytokins IL-5 und aktivierter eosinophiler Granulozyten lässt eine unspezifische Hypersensitivitätsreaktion auf exo- und endogene Stimuli vermuten. Die häufiger vorkommenden chronisch- rezidivierenden Formen lassen sich durch Glukokortikoide günstig beeinflussen. Der Verlauf ist meist selbstlimitierend, ohne Residuen. Aufgrund von Übergängen in hämatoonkologische Erkrankungen sind Verlaufskontrollen angezeigt.

Wells syndrome

A rare eosinophilic dermatosis, Wells syndrome, also referred to as eosinophilic cellulitis, is characterized by great clinical variability. Typical findings include infiltrated erythematous plaques arising on the extremities. Lesions initially resemble erysipelas/cellulitis, however, they do not improve with antibiotic treatment. Eosinophilic cellulitis is a diagnosis of exclusion that may only be made over the course of the disease, taking into account clinical and characteristic histological findings (flame figures). Although multiple potential triggers have been proposed, the exact etiology remains unresolved. Involvement of abnormal Th2 cells, IL-5, and activated eosinophilic granulocytes suggest a nonspecific hypersensitivity response to exogenous or endogenous stimuli. Corticosteroids may have a beneficial effect on the chronic, recurrent course frequently observed. The disease is often self-limiting, healing without sequelae. Given that transitions to hematological and oncological disorders have been observed, patients should be closely followed up.

Dapsone for Recalcitrant Eosinophilic Annular Erythema: A Case Report and Literature Review

Eosinophilic annular erythema (EAE) is a rare entity of unknown etiology that is possibly related to a hypersensitivity reaction and presents as annular erythematous plaques with tissue eosinophilia. It is classified as a figurate erythema with a controversial relationship to Wells syndrome (WS) in the literature, where it is generally considered a separate entity or subset based on clinical and histopathologic differences. EAE typically presents with recurrent, erythematous, arcuate, and annular plaques on the trunk and proximal extremities. The course of the disease is often chronic, recurrent, and relapsing. Responses to treatment are variable but are typically best with systemic steroids and antimalarials. We report a patient refractory to other therapies who had a striking response to dapsone.

Eosinophilic annular erythema is clinically characterized by central pigmentation reflecting basal melanosis: a clinicopathological study of 10 cases

BACKGROUND

Eosinophilic annular erythema (EAE) has been proposed as a clinical entity to describe annular skin lesions associated with tissue eosinophilia. However, systematic investigations on the histopathology of EAE have not been performed, and useful histopathological findings for diagnosis of EAE remain unknown.

OBJECTIVE

The aim of this study was to investigate the clinicopathological features of EAE.

METHODS

We retrospectively studied 10 patients at our hospital during a 5-year span who clinically showed annular or figurate lesions and histopathologically exhibited eosinophilic infiltration in the dermis.

RESULTS

Nine of the 10 cases had annular lesions with pigmentation on the interior side. Blood eosinophilia was found in only one patient. Histopathologically, basal melanosis was observed in nine cases. Infiltration of eosinophils was confined to the dermis in nine cases. Patients treated with systemic corticosteroid tended to show less recurrence than those treated with topical corticosteroid.

LIMITATIONS

The main limitation of our study is the small number of patients.

CONCLUSION

Skin biopsy should be performed when EAE is suspected, even in cases without blood eosinophilia. Basal melanosis and tissue eosinophilia confined to the dermis suggest the diagnosis of EAE. We recommend topical corticosteroids as the initial treatment for EAE.

Treatment of eosinophilic cellulitis (Wells syndrome) - a systematic review

Eosinophilic cellulitis (Wells syndrome) is a rare inflammatory skin disease defined by erythematous, tender, sometimes urticarial plaques, possibly with vesicles and bullae, and granulomatous eosinophilic infiltrates in the dermis. Usually the disease has a benign course with spontaneous remission within a few weeks. Nevertheless, recurrences are quite frequent and may occur for several years. The objective of this study was to review the so far reported treatment options for Wells syndrome in a systematic manner. This systematic review is based on a search on Medline, Embase and Cochrane Central Register for English and German articles from 1970 to 2015. Advices on the treatment of Wells syndrome are limited predominately to case reports or to small case series. There are no randomized controlled trials, and control groups are missing. A variety of treatment options for Wells syndrome were reported including topical and systemic corticosteroids, antihistamines, cyclosporine, dapsone, azathioprine, griseofulvin, doxycycline, minocycline, antimalarial medications, oral tacrolimus/topical tacrolimus, sulfasalazine, interferon alpha and gamma, TNF alpha inhibitors, colchicine and PUVA therapy. As well-designed, randomized controlled trials are missing, no guidelines for the treatment of this disease can be given. Due to the small number of patients and the frequent misdiagnosis of this clinical entity, the aim of this systematic overview is to call attention to this rare condition and to help clinicians to diagnose and treat Wells syndrome effectively. Due to the good prognosis and tendency to resolve, systemic treatment should be limited to cases resistant to local therapy or with widespread lesions.

Eosinophilic annular erythema: A late but complete response to hydroxychloroquine

A 69-year-old woman with a 12-month history of asymptomatic erythematous, non-scaly, annular and arciform plaques on her face, trunk and extremities is presented. The skin lesions had been unresponsive to treatment with systemic corticosteroids and antihistamines. Skin biopsy demonstrated superficial and deep dermal inflammatory infiltration consisting mainly of eosinophils and a few neutrophils. Dermal interstitial mucin deposition was also detected in the absence of vasculitis, flame figures or granulomatous reaction. The patient was diagnosed as having eosinophilic annular erythema and treated with hydroxychloroquine (2 × 200 mg/day, p.o.). Response to treatment was observed after 7 weeks and full recovery was achieved after 10 weeks. Eosinophilic annular erythema is rarely reported in the literature. Although hydroxychloroquine is a good choice for treatment, response time can vary between patients.

Eosinophilic annular erythema: successful response to ultraviolet B therapy

Eosinophilic annular erythema (EAE) is a rare and relatively newly described eosinophil-rich dermatosis. Debate still exists as to whether it represent a subtype of Well syndrome or a separate disease entity. We report an 8-year-old boy with a 4-year history of recurrent, asymptomatic annular lesions, which were diagnosed after clincopathological correlation as EAE. This condition usually runs a relapsing and remitting course with resistance to multiple treatments. Prednisolone and hydroxychloroquine have been reported as successful but the response to these was limited in this case. Complete resolution occurred after treatment with ultraviolet B (UVB) therapy. To our knowledge, this is the first report of a favourable response of EAE to such therapy.

Diagnosis and management of eosinophilic cellulitis (Wells' syndrome): A case series and literature review

INTRODUCTION

Eosinophilic cellulitis (Wells' syndrome) is an inflammatory dermatitis that is often misdiagnosed as infectious cellulitis due to its similarity in presentation. Misdiagnosis leads to delay of correct treatment and inappropriate use of antibiotics.

METHODS

A case series of eosinophilic cellulitis and a literature review are presented.

RESULTS

Patients with Wells' syndrome may present with a variety of nonspecific symptoms, such as fever, arthralgia and malaise, as well as myriad cutaneous lesions with associated erythema, presenting as blisters, bullae, papules and/or nodules. Several treatment modalities have been used to treat eosinophilic cellulitis and have been met with variable success rates; these include systemic corticosteroids, topical corticosteroids and antihistamines, with success rates of 91.7%, 50% and 25%, respectively.

CONCLUSIONS

A high degree of clinical suspicion must be exercised to diagnose this rare condition. Cellulitis with an atypical presentation or not responding to appropriate antibiotic treatment should trigger suspicion of Wells' syndrome. To date, the most successful treatment method is a short course of systemic corticosteroids.

Current knowledge in inflammatory dermatopathology

The complex and fascinating spectrum of inflammatory skin disease, and the comprehension of it, is ever expanding and evolving. During the first decade of the 21st century, numerous advances in the understanding of inflammatory disease mechanisms have occurred, particularly in psoriasis and atopic dermatitis. Continuation of this trend will assure a future in which molecular tests for biomarkers of immediate clinical relevance are used in routine patient care, not only for diagnosis but also for prognosis and management. This article focuses on selected recent or noteworthy developments that are clinically relevant for the histologic diagnosis of inflammatory skin diseases.

Eosinophilic annular erythema is a peculiar subtype in the spectrum of Wells syndrome: a multicentre long-term follow-up study

BACKGROUND/OBJECTIVE

Eosinophilic annular erythema (EAE) was proposed to describe annular skin lesions associated with tissue eosinophilia, however, its relation to Well's syndrome (WS) remains a source of controversy. We studied a series of patients to increase awareness of this entity and to clarify its relation to WS.

METHODS

A multicentre study in which the clinical records, histological findings, laboratory results, therapeutic responses and follow-up of 10 patients were demonstrated.

RESULTS

The study included seven women and three men with age ranging from 31 to 54 years. The duration of the disease ranged from 3 to 28 months. All patients showed involvement of trunk and extremities. Early lesions were manifested as erythematous plaques, which progressed to well-developed figurate lesions and ended as large annular lesions with pigmented centre and elevated border. Flame figures were only observed in well-developed and long-standing lesions. Blood eosinophilia was found in all patients with different grades. Associated disorders included chronic gastritis, diabetes mellitus, chronic hepatitis-C virus infection and chronic kidney disease. The disease showed chronic course with high relapse rate and resistance to various therapeutic modalities including systemic steroid alone and in combination with hydroxychloroquine and cyclosporine.

CONCLUSION

We believe that EAE is a peculiar clinical variant in the spectrum of WS, which is characterized by a chronic course, resistance to treatment and high relapse rate. The diagnosis and evaluation of this condition need a close monitoring with repeated clinical, histological and laboratory assessment.