Annular Lesions: Diagnosis and Treatment

 

Am Fam Physician. 2018 Sep 1;98(5):283-291.

Author disclosure: No relevant financial affiliations.

Annular lesions can present in a variety of diseases. Knowledge of the physical appearance and history of presentation of these skin findings can help in the diagnosis. A pruritic, annular, erythematous patch that grows centrifugally should prompt evaluation for tinea corporis. Tinea corporis may be diagnosed through potassium hydroxide examination of scrapings. Recognizing erythema migrans is important in making the diagnosis of Lyme disease so that antibiotics can be initiated promptly. Plaque psoriasis generally presents with sharply demarcated, erythematous silver plaques. Erythema multiforme, which is due to a hypersensitivity reaction, presents with annular, raised lesions with central clearing. Lichen planus characteristically appears as planar, purple, polygonal, pruritic papules and plaques. Nummular eczema presents as a rash composed of coin-shaped papulovesicular erythematous lesions. Treatment is aimed at reducing skin dryness. Pityriasis rosea presents with multiple erythematous lesions with raised, scaly borders, and is generally self-limited. Urticaria results from the release of histamines and appears as well-circumscribed, erythematous lesions with raised borders and blanched centers. Annular lesions occur less commonly in persons with fixed drug eruptions, leprosy, immunoglobulin A vasculitis, secondary syphilis, sarcoidosis, subacute cutaneous lupus erythematosus, and granuloma annulare.

The word annular is derived from the Latin word annulus, meaning ringed. Many diseases present with cutaneous annular lesions, making distinction by physical appearance alone challenging. This review highlights the physical appearance of and historical findings associated with these lesions, which can aid in diagnosing common and uncommon diseases (Table 1). The management of conditions that cause annular lesions is also discussed.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

A potassium hydroxide preparation of peripheral scale is a reliable test to confirm the diagnosis of tinea corporis.

C

1

Skin hydration with emollients should be included in the basic therapy for nummular eczema.

C

19, 20

Lesions consistent with pityriasis rosea that do not resolve spontaneously in three months should be considered for biopsy.

C

2830

In patients with acute immunoglobulin A vasculitis, the administration of systemic corticosteroids reduces joint and abdominal pain but does not reduce the risk of nephritis.

A

3840


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

A potassium hydroxide preparation of peripheral scale is a reliable test to confirm the diagnosis of tinea corporis.

C

1

Skin hydration with emollients should be included in the basic therapy for nummular eczema.

C

19, 20

Lesions consistent with pityriasis rosea that do not resolve spontaneously in three months should be considered for biopsy.

C

2830

In patients with acute immunoglobulin A vasculitis, the administration of systemic corticosteroids reduces joint and abdominal pain but does not reduce the risk of nephritis.

A

3840


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

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TABLE 1

Diseases That Can Cause Annular Lesions

Common annular lesionsUncommon annular lesions

Common diseases:

Erythema migrans

Erythema multiforme

Lichen planus

Pityriasis rosea

Plaque psoriasis

Tinea corporis

Urticaria

Uncommon diseases:

Fixed drug eruption

Granuloma annulare

Leprosy

Subacute cutaneous lupus erythematosus

Common disease:

Nummular eczema

Uncommon diseases:

Immunoglobulin A vasculitis

Sarcoidosis

Secondary syphilis

TABLE 1

Diseases That Can Cause Annular Lesions

Common annular lesionsUncommon annular lesions

Common diseases:

Erythema migrans

Erythema multiforme

Lichen planus

Pityriasis rosea

Plaque psoriasis

Tinea corporis

Urticaria

Uncommon diseases:

Fixed drug eruption

Granuloma annulare

Leprosy

Subacute cutaneous lupus erythematosus

Common disease:

Nummular eczema

Uncommon diseases:

Immunoglobulin A vasculitis

Sarcoidosis

Secondary syphilis

The Authors

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KATHRYN P. TRAYES, MD, is an assistant professor in the Department of Family and Community Medicine at Thomas Jefferson University Hospital, Philadelphia, Pa....

KATHERINE SAVAGE, MD, is a resident in the Department of Family Medicine at Drexel University College of Medicine, Philadelphia.

JAMES S. STUDDIFORD, MD, is a professor in the Department of Family and Community Medicine at Thomas Jefferson University Hospital.

Address correspondence to Kathryn P. Trayes, MD, Thomas Jefferson University, 1020 Locust St., Ste. 157, Philadelphia, PA 19107 (e-mail: kathryn.trayes@jefferson.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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