Figurate Erythemas - Clinical Tree

A number of cutaneous diseases can have an annular, arciform, or polycyclic configuration, from urticaria to granuloma annulare and tinea corporis ( Table 15.1 ). Sites of involvement, rate of expansion, and characteristics of the border assist in narrowing the differential diagnosis, along with histopathologic examination of the active edge. This chapter discusses in more detail the classic figurate erythemas.

Table 15.1

Additional entities that can have an annular, arciform, or polycyclic configuration.

These disorders are covered in other chapters. See text for discussion of the classic figurate erythemas. Both erythema multiforme and erythema migrans can have a bull’s-eye appearance. CTCL, cutaneous T-cell lymphoma; DIF, direct immunofluorescence.

No epidermal (surface) changes
Annular urticaria	Individual lesions are transient, lasting <24 hrs
Urticaria multiforme	Migratory edematous plaques that may have dusky centers; edema of the face, hands and feet can develop; primarily in infants and young children, often following a viral or bacterial infection
Serum sickness-like eruption	Urticarial (or morbilliform) eruption due to a systemic medication; may be accompanied by arthralgias, arthritis, and fever
Urticarial vasculitis	Individual lesions usually last >24 hrs and may resolve with petechiae
Granuloma annulare	Skin-colored to dull pink elevated border, often composed of coalescing papules; favors acral sites, elbows
Annular elastolytic giant cell granuloma	Chronically sun-exposed sites with significant photodamage; hypopigmented centrally as expands
Interstitial granulomatous dermatitis	Associated with autoimmune connective tissues diseases, e.g. rheumatoid arthritis, and systemic medications, e.g. TNF inhibitors
Sarcoidosis	Skin-colored to red-brown; with pressure (diascopy), has a yellow-brown color; face > trunk, extremities; sometimes has scale
Leprosy	Primarily tuberculoid and borderline forms, with the former often having central hypopigmentation
Syphilis	Secondary stage, in particular on the face, and tertiary stage (gummas); facial lesions may have central hyperpigmentation
Annular erythema of infancy	Slowly expanding with an urticarial border; individual lesions spontaneously resolve over a few days
Benign lymphocytic infiltrate (of Jessner)	Favors the head, neck, and upper trunk; erythematous papules and plaques last weeks to months
LE tumidus	Firm erythematous plaques that favor the face and upper trunk
Lymphoma cutis, both B- and T-cell	Pink to violet papules and plaques; may be primary cutaneous or related to a systemic lymphoma; some subtypes of CTCL, e.g. mycosis fungoides, can have scale

Scale and/or crust
Tinea corporis	Scale and pustules in the advancing border; KOH examination is positive for hyphae
Seborrheic dermatitis	Lesions on the face and central chest; associated scale
Annular psoriasis	Scale is silvery; associated scalp, intergluteal, and nail involvement
Subacute cutaneous LE	Primarily sun-exposed sites, especially upper trunk and upper outer arms; hypopigmented centrally
Elastosis perforans serpiginosa	Border contains keratotic papules and lesions favor flexural sites

Wickham striae within border
Annular lichen planus	The elevated border is string-like

Petechiae within border
Annular capillaritis	Both petechiae and yellow-brown hue due to hemosiderin

Vesicobullae within border
Linear IgA bullous dermatosis	Border may resemble “string of pearls”; DIF required

More serpiginous border
Cutaneous larva migrans	Favors feet, buttocks, and areas in contact with sandy ground

Erythema Annulare Centrifugum (EAC)

Annular, arciform, and polycyclic plaques due to infiltrates of lymphocytes within the dermis; lesions usually last for a few weeks to months and as they migrate centrifugally, there is central clearing; recurrences are common.
This gyrate erythema is sometimes divided into superficial and deep forms, based on clinicopathologic findings, with the superficial form being minimally elevated with “trailing” white scale ( Fig. 15.1A ) and the deep form having a more infiltrated border ( Fig. 15.1B ); some authors reserve the designation EAC for the superficial form.
Color varies from pink to darker red-violet, with the superficial form favoring the thighs and the deeper form the trunk; peak incidence is during the fifth decade.
Often idiopathic, but some cases appear to be a reactive process triggered by fungal infections, in particular tinea pedis, or less often, viral infections or medications.
DDx: Tinea corporis (especially if scale is present); if no surface changes, annular urticaria ( Fig. 15.2 ), benign lymphocytic infiltrate (of Jessner), cutaneous lymphoid hyperplasia, cutaneous lupus erythematosus (tumidus), and lymphoma cutis as well as the other entities covered in this chapter and Table 15.1 ; in some patients, the diagnosis of EAC is rendered after exclusion of other disorders.
Rx: if trigger identified, it should be treated; if no trigger is identified, topical CS may be of some benefit.