Sir,
Erythema gyratum repens (EGR) is exceptionally rare but clinically distinctive condition
characterized by multiple, annular, rapidly growing erythematous plaques with a trailing
scale. The whole pattern of the eruption resembles wood grain. Although the etiology
of EGR is not known, in more than 80% of the cases, an underlying malignancy is found.
So it is considered as the most specific paraneoplastic syndrome.[1] Very rarely,
EGR has been reported in healthy individuals.[2] Here we are presenting a case of
erythema gyratum repens like figurate erythema in a healthy individual which responded
to topical steroid.
A 60-year-old man presented with an 18 months history of pruritic annular scaling
eruption covering his trunk and extremities. Lesions first appeared on his abdomen
and spread gradually to cover most of his trunk. Before presentation he had received
treatment for presumed tinea corporis with topical and oral antifungal but without
any improvement. He also had received treatment for presumed psoriasis with mid potent
topical steroid with good resolution but it recurred after stopping steroid. There
was no history of treatment with retinoids. His medical history disclosed hypertension
and he is on oral metoprolol. Physical examination revealed a well-appearing man with
erythematous, scaling plaques arranged in concentric swirls involving trunk, thighs
and arms. White scale bordered many of the plaques [Figure 1]. The face, oral mucosa,
conjunctivae, acral surfaces, nails, and genitalia were normal. There was no clinically
appreciable lymphadenopathy. A full review of systems revealed negative findings.
Figure 1
Concentric circles with advancing border with trailing scales
Complete blood cell count, peripheral blood smear, 10% KOH for fungal elements, urinalysis,
stool tests for parasites and occult blood, erythrocyte sedimentation rate, ANA, RF,
AntiHIV, C3, C4, serology for viral hepatitis B and C, Chest X-ray and Ultrasonography
of abdomen were within normal limits or negative. Biopsy specimen revealed a hyperkeratosis
and acanthotic epidermis with parakeratosis [Figure 2] and underlying perivascular
lymphocytic infiltrate [Figure 3].
Figure 2
Histopathology revealing hyperkeratosis, acanthosis with perivascular lymphocytic
infilteration (H and E, ×10)
Figure 3
Perivascular lymphocytic infilteration (H and E, ×40)
The patient was treated with topical mid potent steroid twice daily. His examination
at 1 week demonstrated near total resolution of lesions. Mild erythema with slight
scale and post inflammatory hyperpigmentation remained, He was monitored for 5 months,
and continued to experience mild pruritus and thin concentric scaling plaques. At
the time of this report, 2 years after presentation, the patient has experienced a
waxing and waning course of gyrate erythematous scaling plaques, well controlled by
midpotency topical corticosteroids. He has not developed signs of internal malignancy
or significant systemic diseases.
In erythema gyratum repens, Gyratum meanscoiled or winding around a central point
and repens from the Latin, meaning to crawl or creep; the name itself describes the
classic eruption of concentric erythematous rings that develop trailing scale at their
edges and advance at a rapid rate (#1 cm per day). All cases have been described in
Caucasians.[3] EGR is associated with an internal malignancy more than 80% of the
time. The figurate eruptioncan precede, occur concurrently, or appear afterthe diagnosis
of the neoplasm.[3] very rarely it is found in healthy male.[2] In our case, clinical
and laboratory investigations did not reveal any underlying disease or malignancy.
Moreover, the other dermatoses mimicking EGR could be excluded by clinical and histopathologic
findings of the lesions.
Erythema annulare centrifugam is characterized by slowly progressing annular erythema
with trailing edge and pruritus. The palms and soles are spared.[4] Inour patient,
concentric bands not forming polycyclic rings, the localization and persistence at
a specific site are not typical for EAC. But the progression of advancing edge at
a very slow rate and waxing and waning course of the lesions are not typical of EGR.
We could be able to rule out erythema chronicum migrans, and erythema marginatum,
by clinical and laboratory data of our patient.
The therapy for the erythema gyratum repens is to identify and treat any underlying
cause which results in the resolution of lesions. In case of malignancy, the resolution
of the eruption occurs after surgery, chemotherapy, or radiotherapy.[3] Our case did
not develop any evidence in favor of malignancy, although two years had passed after
the onset of lesions, indicating that it was not a paraneoplastic condition. Detailed
investigation also didn't reveal a sign of any other underlying disease. Significant
improvement of EGR with topical corticosteroid treatment is highly unusual. Rare reports
of EGR-like eruptions without malignancy demonstrated resolution with topical steroids
and emollients.[5] Our case showed good improvement with topical steroid.
In conclusion, the presented case had an EGR-like figurate erythema with waxing and
waning course, with no identifiable underlying cause and showed significant improvement
with topical steroid. Whether this is a case of true EGR, borderline case in figurate
erythema spectrum, an EGR-like psoriasis, or another less understood pathogenesis
remains unclear.