Annually recurring erythema annulare centrifugum: a case report

Evaluation of Clinicopathological Features and Associated Conditions in Erythema Annulare Centrifugum: A Retrospective Observational Analysis of 63 Patients

INTRODUCTION

Erythema annulare centrifugum (EAC) is a rare reactive disease that typically presents as annular or polycyclic erythematous lesions. There are few studies about EAC in the literature; therefore, data on the pathogenesis of the disease are limited.

OBJECTIVES

We aimed to examine the demographic, clinical, pathological characteristics and associated conditions of the patients with EAC.

METHODS

We analyzed records of the patients with EAC who admitted to our clinic in the last four years retrospectively.

RESULTS

A total of 63 patients, 39 women and 24 men, were included in our study. The mean age of the patients was 47.8±11.2 years. The mean disease duration was 15.54±12 months. The trunk and thigh were the most commonly involved sites (49%, 33%). Associated conditions were identified in 52.3% of the patients. Infections (N = 16), malignancies (N = 6), rheumatic diseases (n=4) and drugs (n=4) were the most common precipitating factors respectively. The most common infections were superficial fungal infections and Helicobacter pylori infection. Histopathologically, 10 patients had deep type and 53 patients had superficial type EAC. We determined that the disease duration from the onset of the disease was longer (12.3 versus 16.2 months) and the number of attacks (1.2 versus 2.8 attacks) was higher in the superficial type when compared to the deep type (P = 0.042, P = 0.038).

CONCLUSIONS

In our study, infections, malignancies and rheumatic diseases were among the most common etiologic factors. We would also like to draw attention to Helicobacter pylori infection as a precipitating factor which may be a novel finding.

Uncommon non-infectious annular dermatoses

Several cutaneous diseases can present with annular lesions, making a distinction by physical appearance alone challenging. They can be distinguished into infectious and non-infectious, and common and uncommon annular dermatoses. Common non-infectious diseases include granuloma annulare, urticaria, and subacute lupus erythematosus. In addition, there are rare non-infectious non-neoplastic annular dermatoses whose nosographic attribution is established, including annually recurring erythema annulare centrifugum (EAC) and annular erythema in Sjögren syndrome and others whose nosographic positioning is still debated. They are neutrophilic figurate erythema, palpable migratory arciform erythema, eosinophilic annular erythema, and annular lichenoid dermatitis of youth. Their etiopathogenesis is largely unknown, although immune-mediated mechanisms are likely involved. It is difficult to establish if they are variants of reaction patterns or separate clinic-pathological entities. In fact, EAC and annually recurring EAC may represent different aspects of the same disease. Palpable migratory arciform erythema is hardly distinguishable from EAC deep type, Jessner-Kanof disease, and lupus tumidus. Neutrophilic figurate erythema and eosinophilic figurate erythema are clinically very similar and differing only in the relative proportion of eosinophils and neutrophils.

Annually Recurring Erythema Annulare Centrifugum: A New Case Series with Review of the Literature

Annually recurring erythema annulare centrifugum (AR-EAC) is a rare variant, characterized by typical annular plaques recurring in the same period of the year. We describe 5 new cases and present a review of the literature. Patients were 3 females and 2 males with an age range of 25–55 years. Multiple annular plaques were located at the thighs in 4 patients and the neck in one patient. In 1 patient, a single lesion was present. Plaques were recurring in summer in 3 cases; in 1 case, in spring; and another patient, in winter since 3–4 years. Lesions were self-healing in few days or weeks. Histologically, the epidermis presented mild acanthosis with patchy spongiosis, slight parakeratosis, and mild exocytosis. There was a perivascular lympho-histiocytic infiltrate of variable intensity in the superficial dermis, with occasional eosinophils. In 1 case, the inflammatory infiltrate reached the deep dermis. Mucin deposition was absent. Phenotyping studies in 1 case revealed a predominance of T cells, with a small B-cell component. Moreover, a moderate number of CD123⁺ plasmacytoid dendritic cells and CD1a⁺ dendritic cells were noted. Fourteen cases of AR-EAC have been published previously. Collectively, patients' age ranged from 16 to 83 years, with a mean age of 47 years and a disease duration of 1–30 years. Lesions affected more frequently extremities and recurred most commonly in summer. Patients were all in good general health. Topical corticosteroids were the mainstay of treatment. AR-EAC is a benign disorder, the nature of which remains enigmatic.

Recurrent Erythema Annulare Centrifugum due to Influenza Type A

Erythema annulare centrifugum (EAC) is a rare erythema characterized by erythematous and urticarial papules or annular plaques that enlarges centrifugally. The lesions usually involve the thighs and the legs. Several disorders are occasionally associated with EAC, infections, including mycoses, bacteria, or viruses and drugs have also been regarded as possible causes of this eruption. We present a 42-year-old dark-skinned woman affected by recurrent EAC that appeared secondary to influenza type A (H1N1). Histopathology showed a superficial form of EAC. In our case, a previous cytomegalovirus and Epstein-Barr virus (EBV) infection were identified and no underlying other diseases were found. Clarithromycin with calcipotriol betamethasone treatment was temporarily efficacious. In the last 3 years, the lesions started to appear every 2 weeks and tended to regress with local treatment after a variable period. We believe that the latent cytomegalovirus and the reactivity induced by EBV combined with influenza can determine, in our case, a cell mediate cutaneous immune response, which leads to the peculiar inflammatory disease known as EAC.