Erythema Annulare Centrifugum: First Steps and Pitfalls

Gyrate Erythemas, Figurate Erythemas, and Migratory Erythemas

Gyrate erythemas are reactive processes. The therapeutic strategy is to determine and treat the underlying cause, and the cutaneous reaction is then cured. Underlying malignancy; dermatophyte, candidal, or bacterial infection; and ingestants including medications, alternative/complementary medications, and colorings and dyes may all be triggers. The treatment is otherwise supportive. Gyrate erythemas are divided into superficial and deep types, the superficial types having the classic annular morphology and the "trailing" scale. The deep type is usually "urticarial" lesions, with no scale. This discussion does not apply to the following members of the erythema group: erythema gyrated repens, which is a rare form almost universally associated with internal malignancy; erythema chronicum migrans, which is the primary stage of Lyme disease; erythema marginatum, which occurs with acute rheumatic fever; and necrolytic migratory erythema, which is associated with a glucagon-secreting tumor.

First Steps

1. Search for an underlying cause, specifically tinea pedis or cruris. A complete physical examination is required, especially if tinea is not found, to rule out an underlying malignancy.
2. If tinea is found, the best results are obtained with systemic therapy for 6-8 weeks. Ultra micronized griseofulvin 250 mg twice to three times daily with food, two cycles of itraconazole 200 mg twice daily for 7 days separated by 3 weeks of no treatment or terbinafine 250 mg daily. Topical antifungals may not adequately reduce the tinea for the gyrate erythema to clear; however, they should be used in addition (terbinafine or butenafine cream once daily for 1 month.)
3. Topical calcipotriene 0.005% cream twice daily has anecdotally been beneficial.
4. Systemic corticosteroids will improve most cases but should only be administered for short periods, and only after a search for an underlying cause has been performed. Occasionally, empiric therapy with an antifungal, antibacterial, or anticandidal agent, even in the absence of documented infection, will lead to resolution.

Pitfalls

1. Failure to evaluate and re-evaluate for an underlying cause may result in the persistence of the cutaneous reaction.
2. Lupus erythematosus, sarcoidosis, syphilis, and rarely cutaneous T-cell lymphoma may present as gyrate erythema. A biopsy is indicated in all but the most classic cases and if lesions persist.