Scaly, pruritic lesions with poorly demarcated borders. Pityriasis rosea may first present as a herald patch: a single erythematous lesion with raised, scaly borders Figure 7. Within two weeks, diffuse cutaneous involvement occurs with the eruption of multiple, round or ovoid, collarette lesions with scaly borders. Pityriasis rosea is self-limited and usually resolves within six to eight weeks.
Topical corticosteroids and oral antihistamines can be used to alleviate pruritus. There is some evidence that acyclovir and phototherapy may be effective. Pityriasis rosea. Classic herald patch demonstrating central clearing. Urticaria is a condition that develops in response to the release of histamines, resulting in increased vascular permeability and massive edema in the superficial dermis. The edema creates well-circumscribed, ery thematous lesions with raised borders and blanched centers Figure 8.
Urticarial lesions are precipitated by three types of events: allergic, physical, or idiopathic. The diagnosis is based on clinical appearance.
Treatment consists of avoiding triggers; for symptomatic relief, histamine blockers may provide some benefit. Multiple raised, erythematous, round lesions. The rash caused by a fixed drug eruption is characterized by groups of erythematous or violaceous patches or plaques Figure 9. The rash develops 30 minutes to eight hours after ingestion of the drug.
Sulfa drugs and nonsteroidal anti-inflammatory drugs are the most common causative agents. First-generation antihistamines and topical corticosteroids may provide temporary symptomatic relief. Resolution occurs within seven to 10 days of stopping the causative drug; however, postinflammatory hyperpigmentation may persist.
Fixed drug eruption. Violaceous, annular patches with areas of hyperpigmentation. Leprosy, also called Hansen disease, is caused by the bacteria Mycobacterium leprae. It is rare in the United States; most cases occur in patients who have lived in foreign countries.
The skin lesions present as erythematous annular plaques with or without scales Figure The lesions may appear hypopigmented in dark-skinned persons.
Patients may have decreased sensation to pain, temperature, and touch over the lesions. The preferred method of diagnosis is polymerase chain reaction testing or Fite-Faraco staining of a biopsy of the lesions. The rash presents as violaceous ecchymoses, petechiae, and palpable purpura Figure The diagnosis can be made clinically based on the presentation of skin lesions with arthritic symptoms and colicky abdominal pain.
If clinical findings are inconclusive, a complete blood count, urinalysis, IgA levels, and skin and kidney biopsies should be ordered. Diagnostic biopsies will show prominent IgA deposition. Immunoglobulin A vasculitis. Violaceous, palpable purpuric lesions. Treatment involves pain management with nonsteroidal anti-inflammatory drugs or acetaminophen. Systemic corticosteroids can minimize the severity of joint and abdominal pain.
The rash of secondary syphilis is diffuse, symmetric, erythematous, and annulopapular Figure It typically involves the trunk, extremities, palms, and soles, and may be accompanied by an influenza-like prodrome. The diagnosis is made by rapid plasma reagin testing confirmed by treponemal testing. The preferred treatment is parenteral penicillin G benzathine. New cases of secondary syphilis must be reported to the Centers for Disease Control and Prevention.
Secondary syphilis. Hyperpigmented round lesions on palms. The rash of sarcoidosis is characterized by erythematous, indurated plaques Figure It is more common in black patients 10 to 39 years of age. The recommended workup for sarcoidosis includes skin biopsy, chest radiography or high-resolution computed tomography, tuberculosis skin testing, pulmonary function testing, and ophthalmologic examination to assess for uveitis.
Differential diagnosis of annular lesions. Am Fam Physician. There is no cure for sarcoidosis; treatment is aimed at alleviating symptoms. First-line therapies include topical and systemic corticosteroids. Hydroxychloroquine Plaquenil , chloroquine Aralen , methotrexate, and thalidomide are alternatives for patients who cannot tolerate corticosteroids or whose symptoms do not respond to initial treatment. Subacute cutaneous lupus erythematosus most commonly develops in women 20 to 39 years of age.
Skin lesions develop in sun-exposed areas of the body Figure Treatment begins with minimizing sun exposure through the use of sunscreen. Topical corticosteroids may also be used; systemic corticosteroids, hydroxychloroquine, dapsone, thalidomide, methotrexate, and retinoids may benefit patients with more severe disease. Subacute cutaneous lupus erythematosus.
Red, annular lesions with some atrophy and minimal scaling. Systemic lupus erythematosus: primary care approach to diagnosis and management. Granuloma annulare is characterized by firm, shiny papules that can be violaceous, erythematous, or brown or flesh-colored with central involution Figure The lesions most commonly develop on the dorsal side of the hands and feet.
Granuloma annulare can be associated with type 1 diabetes, dyslipidemia, and some malignancies. Isotretinoin and dapsone may be used to treat widespread disease; however, evidence of their effectiveness is limited by a lack of clinical trials. These agents pose a significant risk of toxicity and have numerous adverse effects. Granuloma annulare lesions usually resolve spontaneously within two years. Granuloma annulare. Brownish-red lesion on the dorsal wrist with a ringed lesion extending around the hand.
This article updates a previous article on this topic by Hsu, et al. Data Sources: A PubMed search was completed in Clinical Queries using the terms annular lesions, tinea corporis, Lyme, plaque psoriasis, erythema multiforme, lichen planus, nummular eczema, pityriasis rosea, herpes simplex virus type 1, and urticaria.
The search included meta-analyses, systematic reviews, clinical trials, and reviews. Search dates: May, August, and September , and July Already a member or subscriber? Log in. Interested in AAFP membership? Learn more. Address correspondence to Kathryn P. Reprints are not available from the authors. Diagnosis and management of tinea infections. Topical antifungal treatments for tinea cruris and tinea corporis. Cochrane Database Syst Rev.
J Emerg Med. Centers for Disease Control and Prevention. Signs and symptoms of untreated Lyme disease. October 26, Accessed May 10, Diagnosis, treatment, and prognosis of erythema migrans and Lyme arthritis. Clin Dermatol. Owolabi T, Simpson I. An annular rash. The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America [published correction appears in Clin Infect Dis.
Clin Infect Dis. Diagnosis and management of Lyme disease. Chronic plaque psoriasis. Menter A, Griffiths CE. Current and future management of psoriasis. Weigle N, McBane S. Detection of herpes simplex virus genomic DNA in various subsets of erythema multiforme by polymerase chain reaction. Precipitants in 42 cases of erythema multiforme. Further physical and laboratory tests have found that she had oral ulcers, proteinuria, thrombocytopenia and abnormal titer of anti-nuclear antibody satisfying the diagnosis of SLE.
From this case, we think unilateral erythematous patches on face could be a rare manifestation of SLE and more intention should be paid to this type of patients, because unilateral facial symptom may mimic other dermatoses. Keywords: Cutaneous lupus; cutaneous manifestations; systemic lupus erythematosus; unilateral. Abstract Systemic lupus erythematosus SLE is a chronic autoimmune disorder that can have many cutaneous manifestations including malar rash, discoid rash or oral ulcer.
The pathophysiological mechanism of these symptoms remains largely unknown. But previous studies in patients with AGEP have revealed a high rate of positive patch test responses and in vitro lymphocyte proliferative responses compared with other drug eruption. This strongly suggests that this adverse cutaneous reaction occurs by a drug-specific T-cell-mediated process 3.
These specific T-cells produce large amounts of cytokines, which contribute to the accumulation of neutrophils 4. ALEP is a less common form of pustular drug eruption, in which lesions are consistent with the characteristics of AGEP but are typically localized to the face, neck or chest.
Prange 5 and colleagues first defined ALEP in They described a woman whose symptoms fit the criteria of AGEP but whose lesions were localized to the face. To the best of our knowledge, only nine separate case of this variant has been reported. Two cases occurred following administration of amoxicillin-clavulanic acid 5 , 6 , four following administration of amoxicillin only 6 - 9 , and one after administration of levofloxacin Other causative drugs aside from antibiotics include ibuprofen 3 and paracentamol in pregnant woman In reported cases, the lesions are consistent with the characteristics of AGEP but are localized typically to the face, neck, and chest.
In the present case, the Sweet syndrome acute febrile neutrophilic dermatosis should be differentiated. Typical findings of the Sweet syndrome include the sudden appearance of a fever, increased neutrophilic count, erythematous papules, pustules on the head, neck, and extremities and infiltration of neutrophils throughout the dermis. However, in the Sweet syndrome, the lesions are usually tender and there is no evidence of leukocytoclastic vasculitis in the dermis Histologically, the subcorneal pustules of ALEP resembled those of pustular psoriasis or subcorneal pustulosis.
Recent drug administration history, no personal history of psoriasis, more acute course and rapid spontaneous healing allowed us to differentiate the diagnosis from other pustular dermatoses The most important aspect of treatment is the immediate withdrawal of the suspected agent and supportive therapy. Other specific treatments are not usually needed, because ALEP is a self-limited disease with a favorable prognosis in most cases 3.
However, topical or systemic corticosteroids can be helpful because of their anti-inflammatory properties In our case, the lesions developed rapidly after administration of antibiotics and were resolved within several days of discontinuing the treatment.
Based on this histologic findin, the symptoms appeared to correspond to AGEP, which results in unusual characteristics that are limited on the face. All antibiotics that had been used in this case can lead AGEP. However, only two cases attributed to vancomycin have been reported Cephalosporins are relatively common causative drugs for AGEP, but interestingly not sulfonamides, who have a high potential of causing other drug eruptions 1.
Therefore, we assumed that cephalosporins were the causative drug in this case. Further study may be required to facilitate the correct diagnosis and treatment for this rare disorder. National Center for Biotechnology Information , U. Journal List Ann Dermatol v. Ann Dermatol. Published online Dec Hyun Soo Sim , M. Find articles by Hyun Soo Sim. Find articles by Jung Eun Seol.
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