Photo Quiz

Erythematous Annular Lesions

Am Fam Physician. 2007 Dec 1;76(11):1709-1710.

A 59-year-old man presented with a six-week history of erythematous plaques with dusky, scaly centers (see accompanying figure) on his neck, torso, and extremities. The lesions were nonpruritic and appeared simultaneously. Hydrochlorothiazide (Ezide) was the patient's only long-term medication, and he was not taking any new medications, including antibiotics.

Question

Based on the patient's history and physical examination, which one of the following is the most likely diagnosis?

A. Cutaneous sarcoidosis.

B. Erythema multiforme.

C. Generalized granuloma annulare.

D. Subacute cutaneous lupus erythematosus.

E. Sweet's syndrome.

Discussion

The answer is D: subacute cutaneous lupus erythematosus (SCLE). Cutaneous lupus erythematosus is categorized as acute, subacute, or chronic.1 Skin manifestations of SCLE may be associated with systemic disease, including renal and central nervous system involvement.2 SCLE usually affects white women 30 to 40 years of age,1 and it often causes eruptions on sun-exposed areas.3 The lesions may be annular or papulosquamous with crusted margins, mimicking psoriasis.1

Although genetic deficiencies in the C2 and C4 complement components are linked to SCLE, environmental factors may be more important in the pathophysiology of the disease.3 Use of medication, particularly hydrochlorothiazide, antihistamines, calcium channel blockers, terbinafine (Lamisil), or naproxen (Naprosyn), is the most common environmental factor related to the disease.3,4

Follicular plugging is a common finding in patients with cutaneous lupus erythematosus; however, it is less likely to occur with subacute disease.5 Although performing the lupus band test with direct immunofluorescence is not always necessary, the test will reveal a band-like pattern of granular or globular deposits of immunoglobulin G (IgG), IgM, and C3.3,5 In classic cases, test results are often positive for antinuclear and anti–SS-A antibodies and negative for double-stranded anti-DNA antibodies.3 However, a full work-up for systemic lupus should be performed.

Initial treatment of SCLE includes using sunscreen and avoiding causative medications, although the lesions may persist.3 Treatment with topical, potent steroids (e.g., clobetasol [Temovate], betamethasone [Beta Derm]); intralesional steroids; or a pulsed dye laser can be effective for localized lesions. Refractory lesions often require systemic treatment with hydroxychloroquine (400 mg per day). Severe cases may require methotrexate, systemic retinoids, thalidomide (Thalomid), or dapsone.3

Cutaneous sarcoidosis features reddish-brown to purple plaques that can scar, ulcerate, or become nodular. Systemic involvement may include the lungs, liver, spleen, eyes, lymph nodes, or salivary glands. Skin biopsy reveals noncaseous granulomas.6

Erythema multiforme often affects young patients with a flare-up of herpes simplex virus (HSV) and occurs as target-like lesions on the palms of the hands, soles of the feet, face, and genitalia.1,6 Although most cases are idiopathic or caused by HSV, erythema multiforme also has been associated with Mycoplasma infection and the use of sulfonamides, phenytoin (Dilantin), barbiturates, phenylbutazone (no longer available in the United States), penicillin, and allopurinol (Zyloprim).1

Granuloma annulare is characterized by localized, pruritic, erythematous or flesh-colored, annular plaques that usually occur on the extremities. The disease is idiopathic and often resolves within two years. Generalized granuloma annulare is a subset of the disease that causes a wide distribution of more than 10 lesions. This form is less likely to remit and may require symptomatic treatment because there is no cure.6

Sweet's syndrome (acute febrile neutrophilic dermatosis) has been associated with infection, hematologic or solid malignancies, medication use, and pregnancy. The lesions are annular, red, tender papules and plaques, often occurring on the face, neck, and upper extremities. A biopsy is needed to confirm the diagnosis; pathology tests show prominent papillary dermal edema with a dense collection of neutrophils in the reticular dermis without leukocytoclastic insults.1

Selected Differential Diagnosis of Erythematous Annular Lesions

Condition Characteristics

Cutaneous sarcoidosis

Reddish-brown to purple plaques that can scar, ulcerate, or become nodular

Erythema multiforme

Target-like lesions; usually occurs on the palms of the hands, soles of the feet, face, and genitalia

Granuloma annulare

Localized or generalized; pruritic, erythematous or flesh-colored, annular plaques

Subacute cutaneous lupus erythematosus

Erythematous, annular, scaly plaques; occurs on sun-exposed areas

Sweet's syndrome (acute febrile neutrophilic dermatosis)

Annular, red, tender papules and plaques; usually occurs on the face, neck, and upper Extremities

Selected Differential Diagnosis of Erythematous Annular Lesions

View Table

Selected Differential Diagnosis of Erythematous Annular Lesions

Condition Characteristics

Cutaneous sarcoidosis

Reddish-brown to purple plaques that can scar, ulcerate, or become nodular

Erythema multiforme

Target-like lesions; usually occurs on the palms of the hands, soles of the feet, face, and genitalia

Granuloma annulare

Localized or generalized; pruritic, erythematous or flesh-colored, annular plaques

Subacute cutaneous lupus erythematosus

Erythematous, annular, scaly plaques; occurs on sun-exposed areas

Sweet's syndrome (acute febrile neutrophilic dermatosis)

Annular, red, tender papules and plaques; usually occurs on the face, neck, and upper Extremities

Address correspondence to Oliver J. Wisco, DO, at oliver.wisco@amedd.army.mil. Reprints are not available from the authors.

Author disclosure: Nothing to disclose.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Air Force or U.S. Army Medical Departments, or the U.S. Air Force or U.S. Army Services at large.

REFERENCES

1. Wolff K, Johnson RA, Suurmond D. Fitzpatrick's Color Atlas and Synopsis of Clinical Dermatology. 5th ed. New York, NY: McGraw-Hill, 2005.

2. Black DR, Hornung CA, Schneider PD, et al. Frequency and severity of systemic disease in patients with subacute cutaneous lupus erythematosus. Arch Dermatol. 2002;138:1175–8.

3. Patel P, Werth V. Cutaneous lupus erythematosus: a review. Dermatol Clin. 2002;20:373–85.

4. Shapiro M, Sosis AC, Junkins-Hopkins JM, et al. Lupus erythematosus induced by medications, ultraviolet radiation, and other exogenous agents. Int J Dermatol. 2004;43:87–94.

5. Bolognia, JL, Jorizzo JL, Rapini RP. Dermatology. St. Louis, Mo.: Mosby, 2003.

6. Hsu S, Le EH, Khoshevis MR. Differential diagnosis of annular lesions. Am Fam Physician. 2001;64:289–96.

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