Erythema Gyratum Repens Like Figurate Erythema Responding to Topical Steroid in an Healthy Individual

Abstract

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.