| Abstract |
A 61-year-old woman with a remote history of breast cancer
presented with a 30-month course of relapsing and remitting lesions
on the lower back and upper thighs. Examination showed a 13-cm
erythematous, sharply-demarcated polycyclic plaque with a fine
trailing scale and central clearing on the sacral area. There
were also numerous 2 to 5-cm erythematous annular and polycyclic
plaques with central clearing on the bilateral buttocks, upper
thighs, and groin. KOH was negative. Clinical findings and histopathological
results were consistent with a diagnosis of erythema annulare
centrifugum. |
Patient |
61-year-old retired librarian |
Duration |
30 months |
Distribution |
lower back, buttocks, upper thighs |
| History |
The patient is a 61-year-old woman with a remote history
of invasive ductal carcinoma of the breast who presented in
March 2006 with a 30-month course of relapsing and remitting
lesions on the lower back and upper thighs. A 10-cm erythematous,
annular plaque with central clearing initially presented on
her sacral area in late 2003 after she bathed in a hot tub.
It was only mildly pruritic, and she did not seek medical
treatment. Several weeks later the lesion spontaneously cleared.
Two years later, in December 2005, multiple smaller annular
lesions reappeared on her low back, buttocks, and upper thighs
after bathing in a hot spring in Hawaii. There was no recent
history of infection, new medications, or sun exposure. The
lesions were pruritic and did not respond to over the counter
hydrocortisone ointment. She was treated by her primary care
physician with topical ketoconazole cream and oral terbinafine
over a several month period, neither of which was effective.
The lesions enlarged and became more numerous in the several
months prior to her presentation at the dermatology clinic.
Past medical history is significant for surgical excision
of left-sided breast cancer in 1999 followed by chemotherapy,
radiation, and a five year course of tamoxifen completed in
August of 2004. Her most recent mammogram was 8 months ago
and showed no abnormalities. The patient has a history of
congenital deafness, irritable bowel syndrome, carpal tunnel
syndrome, and a herniated disc at L4-5.
Review of systems is negative for oral lesions, easy bruising,
night sweats, weight loss, new joint pain, or tick bites.
Medications: Terbinafine 250 mg once daily, aspirin 80 mg
once daily, Glucosamine 1500 mg once daily, and one multivitamin-calcium
tab daily.
Allergies include antihistamines and sulfonamides.
|
| Physical Examination |
Healthy appearing middle-aged female in
no apparent distress. There is no cervical, supraclavicular,
or axillary adenopathy. There is a 3 cm well-healed scar on
the medial aspect of the left breast without underlying induration.
There are no masses in the left or right breast. On the sacral
area there is a 13-cm erythematous, sharply-demarcated polycyclic
plaque with a fine trailing scale and central clearing. There
are numerous 2 to 5-cm erythematous annular and polycyclic plaques
with central clearing on the bilateral buttocks, upper thighs,
and groin. The margins of the plaques are erythematous, indurated,
and vary in width from 4-6 mm. There is a fine trailing scale.
There is no vesiculation, erosion, or nodularity. The arms,
palms, soles, and face are spared. |
| Images |
|
| Laboratory Data |
Hb 14.6, Hct 41.1, WBC 4,600, plt 199 000. Alkaline phosphatase
105, AST 24, and ALT 17. CA 27.29 tumor marker 4.9 (normal
<38).
KOH stain of skin scraping: negative for fungal hyphae or
spores
|
| Histopathology |
Epidermal spongiosis
and focal parakeratosis with neutrophils in the stratum corneum.
Slight superficial perivascular lymphocytic infiltrate. PAS
stain negative for fungal organisms. No malignant cells.
|
| Diagnosis |
Erythema annulare centrifugum, superficial type. |
|
Reasons Presented |
1. The gyrate erythemas are a diverse group of conditions of
unknown etiology that are difficult to both diagnose and treat.
2. Because gyrate erythemas have been reported in association
with malignancy, this patient’s history of breast cancer
and tamoxifen therapy makes her workup more complex.
|
| Questions |
1. How can one distinguish between erythema annulare centrifugum
from the other gyrate erythemas?
2. What medications, foods, and underlying conditions are associated
with the development of erythema annulare centrifugum?
3. Given the reported association between the gyrate erythemas
and malignancy, should this patient be referred to oncology
for evaluation of possible breast cancer relapse?
|
| References |
Bressler GS, Jones RE Jr: Erythema annulare centrifugum.
J Am Acad Dermatol 1981 May; 4(5): 597-602. (Abstract)
Minni J et al. A novel therapeutic approach to erythema annulare
centrifugum. J Am Acad Dermatol 2006; 54 (3): S143-5.
(Abstract)
Muret MG et al. Annually recurring erythema annulare centrifugum:
A distinct entity? J Acad Dermatol 2006; 54: 1091-5.
(Abstract)
Weyers W et al. Erythema annulare centrifugum: Results of a
clinicopathologic study of 73 patients. Am J Dermatopathol 2003;
25: 451-462. (Abstract)
Weyers W et al. Erythema annulare centrifugum: Results of a
clinicopathologic study of 73 patients. Am J Dermatopathol 2003;
25: 451-462. (Abstract)
|
| Keywords |
erythema annulare centrifugum, gyrate erythema |
| Comments from Faculty and Members |
A.R.Pito MD, Norfolk Island, S.P. on September
10, 2006
I must say, as an old retired dermatologist I am most impressed
with this case presentation. It makes me feel good about medical
student training in the States.
This case seems to be EAC. E. gyratum repens is the figurate
erythems most usually associated with underlying malignancy,
however, I suspect there is some overlap.
I notice that Ms. Mann is from New England. Were serologies
for Lyme Disease done? A negative history of tick bite does
not rule out late Lyme -- and while this is not the picture
of ECM, here, too, there are variants.
Of course if serologies are positive, that opens up another
bag of worms.
How much does the process discomfort the patient? If not much,
leave it be. If if is a problem, why not give narrow band UVB
a try -- quite benign really. Buys you some time, eh? Her oncologist
should know about this and she will decide how far to take the
work-up with your input. Thanks again for this clear, well-presented
case.
Omid Zalgari MD, Rasht, Iran on September
12, 2006
Nice presentation, indeed. I’m impressed as well! …and
I agree with the diagnosis. There are a lot of etiologies for
erythema annulare centrifugum; from just eating blue cheese
to end-stage cancers. I’ve never seen a case of erythema
gyratum repens (EGR), but in my opinion, EGR is just a severe
form of EAC which is caused by more significant diseases. Even,
histologically, I think there is no real difference between
EAC and EGR. Cheers.
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