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Erythema annulare centrifugum

Author: Dr Karen Koch, Dermatologist, Waikato Hospital, Hamilton, New Zealand. DermNet NZ Editor in Chief: Adjunct A/Prof Amanda Oakley, Dermatologist, Hamilton, New Zealand. Copy edited by Gus Mitchell. June 2019.


What is erythema annulare centrifugum?

Erythema annulare centrifugum (EAC) is a chronic reactive form of annular erythema characterised by erythematous, circular, arciform and polycyclic lesions with characteristic delicate scale behind the advancing edge (‘trailing scale’).

Erythema annulare centrifugum

See more images of erythema annulare centrifugum.

Who gets erythema annulare centrifugum?

Erythema annulare centrifugum most often occurs in adults, but all ages can be affected. The average age of onset is 40 years [1].

What causes erythema annulare centrifugum?

Erythema annulare centrifugum has been shown to occur in association with underlying medical conditions and medications in 33–72% of cases [1,2]. It is thought to be a form of hypersensitivity reaction.

The most commonly associated conditions are:

Dietary causes of erythema annulare centrifugum include blue cheese and tomatoes. Stress has also been associated with the disease [1,3].

What are the clinical features of erythema annulare centrifugum?

Erythema annulare centrifugum typically affects the thighs, buttocks and upper arms. However, any location on the body can be affected.

Erythema annulare centrifugum usually starts as a small pink papule that gradually enlarges with central clearing, to form annular lesions over several weeks. These can vary in size from a few millimetres to a few centimetres in size. Annular lesions can be partial (arciform) and coalesce to form polycyclic (ringed), serpiginous (wavy) and gyrate (revolving) patterns.

Classically, the annular or arciform lesions have an advancing outer erythematous edge with a trailing (inner) scaly edge. The rash may be itchy.

How is erythema annulare centrifugum diagnosed?

Erythema annulare centrifugum can sometimes be diagnosed on clinical features alone if the characteristic trailing scale is present. The diagnosis can be confirmed by skin biopsy in which typical features of superficial or deep erythema annulare centrifugum are noted: ‘coat-sleeve’ dense perivascular lymphocytic infiltrate either involving the superficial or deep vascular plexus. Secondary changes to the epidermis may include spongiosis (inflammation of intercellular oedema), parakeratosis (disturbance in the keratinisation process) and hyperkeratosis (thickening of the outer layer of the epidermis) [2].

Investigations for an underlying cause should be guided by history and examination. Age and symptom-appropriate cancer screening should be done.

Toenail clippings and skin scrapings should be submitted for mycology if onychomycosis, tinea pedis, or tinea corporis are suspected.

What is the differential diagnosis for erythema annulare centrifugum?

Several skin conditions should be considered in the differential diagnosis of erythema annulare centrifugum. Conditions to consider include other forms of annular erythema.

  • Erythema perstans — a paraneoplastic eruption associated with underlying malignancy in which there are concentric and whirling rings.
  • Erythema gyratum repens — a paraneoplastic rash with a typical ‘wood grain’ appearance from rapidly expanding erythematous lines in a concentric pattern.
  • Necrolytic migratory erythema — ring-shaped red rashes that blister, erode, and crust over time. It classically occurs with an underlying glucagonoma.
  • Erythema marginatum — a rash occurring in acute rheumatic fever; this classically appears as pink or red macules or papules, which spread outwards in a circular shape.
  • Erythema multiformetargetoid lesions occurring on the backs of hands and tops of feet (but may occur anywhere). The lesions consist of sharply demarcated reddish pink macules that gradually enlarge to form plaques. The central part changes colour or clears, creating rings.
  • Erythema migrans (the first stage of Lyme disease) — an expanding red patch of skin that starts at the site of the tick bite and gradually expands to reach several dozens of centimetres in size.

Other disorders to be considered include:

  • Tinea (dermatophyte infection) — gradually enlarging, itchy and scaly annular lesions with central clearing
  • Granuloma annulare — an annular rash with a rubbery raised smooth erythematous edge with central clearing
  • Erythema papulatum centrifugum — a sweat-related itchy condition where erythematous papules form enlarging annular and arciform structures on the trunk and limbs
  • Secondary syphilis may present with scaly annular and polycyclic plaques which tend not to be itchy
  • Cutaneous lupus erythematosus especially subacute cutaneous lupus erythematosus and systemic lupus erythematosus.

Annular scaly plaques are also common in discoid eczema, chronic plaque psoriasis, seborrhoeic dermatitis, pityriasis rosea, porokeratosis, and sarcoidosis.

What is the treatment for erythema annulare centrifugum?

It is essential to identify and treat the underlying cause of erythema annulare centrifugum where possible, such as a cutaneous fungal infection.

Some medications that have been used to treat erythema annulare centrifugum include:

Local therapy

Systemic therapy

What is the outcome for erythema annulare centrifugum?

Erythema annulare centrifugum tends to recur over several months or years but can spontaneously remit. Kim et al. showed that 18.5% of affected individuals had persistent skin lesions for more than one year and that the average duration of skin lesions was 4.7 months [1].

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References

  1. Kim KJ, Chang SE, Choi JH, et al. Clinicopathologic analysis of 66 cases of erythema annulare centrifugum. J Dermatol 2002; 29: 61–7. PubMed
  2. Kim DH, Lee JH, Lee JY, Park YM. Erythema annulare centrifugum: analysis of associated diseases and clinical outcomes according to histopathologic classification. Ann Dermatol 2016; 28: 257–9. doi:10.5021/ad.2016.28.2.257. PubMed Central
  3. Weyers W, Diaz-Cascajo C, Weyers I. Erythema annulare centrifugum: results of a clinicopathologic study of 73 patients. Am J Dermatopathol 2003; 25: 451–62. PubMed
  4. Kruse LL, Kenner-Bell BM, Mancini AJ. Pediatric erythema annulare centrifugum treated with oral fluconazole: A Retrospective Series. Pediatr Dermatol 2016; 33: 501–6. PubMed
  5. Sardana K, Chugh S, Mahajan K. An observational study of the efficacy of azithromycin in erythema annulare centrifugum. Clin Exp Dermatol 2018; 43: 296–9. PubMed
  6. Yalamanchili R, Shastry V, Betkerur J. Clinico-epidemiological study and quality of life assessment in melasma. Indian J Dermatol 2015; 60: 519. PubMed
  7. De Aloe G, Rubegni P, Risulo M, et al. Erythema annulare centrifugum successfully treated with metronidazole. Clin Exp Dermatol 2005; 30: 583–4. PubMed
  8. Minni J, Sarro R. A novel therapeutic approach to erythema annulare centrifugum. J Am Acad Dermatol 2006; 54: S134–5. PubMed

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