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10 Erythema Conditions You Should Know
Cristina Wojdylo | May 17, 2023
| Contributor Information
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Images courtesy of Chulabhorn Pruksachatkunakorn, MD.
10 Erythema Conditions You Should Know
Cristina Wojdylo | May 17, 2023 | Contributor Information
Erythema Multiforme
Erythema multiforme is an acute, self-limited, and sometimes recurring skin condition that is considered to be a type IV hypersensitivity reaction associated with certain infections, medications, and other various triggers.[1,2] A wide spectrum of severity exists.
Erythema multiforme minor represents a localized eruption of the skin with minimal or no mucosal involvement. The papules evolve into pathognomonic target or iris lesions (left image) that appear within a 72-hour period and begin on the extremities. The lesions remain in a fixed location for at least 7 days and then begin to heal. An arcuate appearance may be present (right image).
Precipitating factors include herpes simplex virus (HSV) or Epstein-Barr virus infection and histoplasmosis. Because this condition may be related to recurrent HSV, recurrences of erythema multiforme may follow, with many affected individuals experiencing several recurrences per year.
Image courtesy of Medscape.
10 Erythema Conditions You Should Know
Cristina Wojdylo | May 17, 2023 | Contributor Information
Erythema Nodosum
Erythema nodosum (EN) is an acute, nodular, erythematous eruption that is usually limited to the extensor aspects of the lower legs (shown). Chronic or recurrent EN is rare but may occur. This condition is presumed to be a hypersensitivity reaction to a variety of antigens and may occur in association with several systemic diseases or drug therapies, or it may be idiopathic. The inflammatory reaction occurs in the panniculus.[3]
Circulating immune complexes have not been found in idiopathic or uncomplicated cases, but they may be seen in patients with inflammatory bowel disease.[4] Currently, the most common pediatric cause of EN is streptococcal infection; in adults, it is streptococcal infection and sarcoidosis.[5]
The eruptive phase of EN begins with flulike symptoms (fever, generalized aching).[3] Arthralgia may occur and precedes the eruption or appears during the eruptive phase. Most lesions in infection-induced EN heal within 7 weeks, but active disease may last up to 18 weeks. In contrast, 30% of idiopathic cases may last more than 6 months. Febrile illness with dermatologic findings includes abrupt onset of illness with initial fever, followed by a painful rash within 1-2 days. Therapy consists of symptomatic relief and treatment of the underlying condition.
Image from Wikimedia Commons | Adsie. [Creative Commons Attribution-Share Alike 4.0 International license (CC by-SA 4.0).]
10 Erythema Conditions You Should Know
Cristina Wojdylo | May 17, 2023 | Contributor Information
Erythema Marginatum
Erythema marginatum is the characteristic macular or papular annular rash with serpiginous borders of acute rheumatic fever; it is located on the trunk, upper arms, and legs.[6] Acute rheumatic fever is a sequela of streptococcal infection—typically following 2-3 weeks after group A streptococcal pharyngitis—that occurs most commonly in children and has rheumatologic, cardiac, and neurologic manifestations.[7,8]
Diagnosis of acute rheumatic fever rests on a combination of clinical manifestations that can develop in relation to group A streptococcal pharyngitis.[9] These include chorea, carditis, subcutaneous nodules, erythema marginatum, and migratory polyarthritis.
No specific treatment exists for erythema marginatum. The lesions are self-limited. Therapy for acute rheumatic fever includes antibiotics, corticosteroids, and management of cardiac, rheumatologic, and other complications.
Left image (shoulder) from the Centers for Disease Control and Prevention (CDC). Right image (upper arm) from the CDC | James Gathany. [Both images are in the public domain.]
10 Erythema Conditions You Should Know
Cristina Wojdylo | May 17, 2023 | Contributor Information
Erythema Migrans
Erythema migrans, the characteristic skin rash of Lyme disease, occurs in about 70-80% of infected persons and develops at an average of 7 days after the tick bite.[10] The rash is usually located at or near the site of the tick bite, which may be an area not normally visualized by affected individuals, such as the axilla, groin, or popliteal fossa.[11] It may be asymptomatic, or it may itch or burn.
The rash typically expands over days and is not evanescent.[11] It may not be observed until it is already full size. Clearing of portions of the rash as it expands may result in concentric rings of erythema, producing the classic bull's-eye rash (shown). In the United States, however, erythema migrans is more likely to have a uniform color.
Treatment consists of antibiotic therapy with regimens of doxycycline, amoxicillin, or cefuroxime in adults and children.
Left image from Wikimedia Commons | Doktorinternet. [CC by-SA 4.0 International.] Right image courtesy of Dirk M Elston, MD.
10 Erythema Conditions You Should Know
Cristina Wojdylo | May 17, 2023 | Contributor Information
Systemic Lupus Erythematosus
The classic malar rash for systemic lupus erythematosus (SLE), also known as a butterfly rash, is distributed over the cheeks and nasal bridge (left image). It lasts from days to weeks and is occasionally painful or pruritic.[11] Fixed erythema, sometimes with mild induration (left image), characteristically spares the nasolabial folds.[11] An appropriate initial workup includes an antinuclear antibody (ANA) test, urinalysis, and double-stranded DNA antibody screen to evaluate the risk for future renal disease.[12]
The rash of subacute cutaneous lupus erythematosus (right image), seen in about 10% of patients with SLE (50% occur in isolation without SLE),[13] has a similar hue to SLE but preferentially affects single covered areas with psoriasiform or polycyclic lesions. The rash tends to be persistent but does not result in scarring. It generally responds very well to antimalarial therapy.
Left image courtesy of Dr. Erik Stratman, Marshfield Clinic. Right image from Wikimedia Commons | Mohammad2018. [CC by-SA 4.0 International.]
10 Erythema Conditions You Should Know
Cristina Wojdylo | May 17, 2023 | Contributor Information
Acute and subacute cutaneous lupus erythematosus are characterized by variable hyperkeratosis (thickening of the cornified layer) and vacuolar alteration of basal layer keratinocytes. The presence of these findings in a photosensitive rash suggests lupus erythematosus or dermatomyositis. The distribution of the rash and degree of pruritus will distinguish the two.
Lupus preferentially affects the phalanges and sun-exposed areas (left image), whereas dermatomyositis affects the scalp, knuckles (right image), extensors, hips (holster sign), and upper back (shawl sign).[14]
Images courtesy of Medscape.
10 Erythema Conditions You Should Know
Cristina Wojdylo | May 17, 2023 | Contributor Information
Erythema Annulare Centrifugum
Erythema annulare centrifugum (EAC), classified as one of the figurate or gyrate erythemas, features a scaling or nonscaling, nonpruritic, annular or arcuate, erythematous eruption (left image).[15] It tends to spread peripherally while clearing centrally (right image).[16] Histologically, an intense lymphohistiocytic cuffing occurs about the superficial and deep dermal vessels without epidermal involvement. The etiology is uncertain, but it may be due to a hypersensitivity to malignancy, infection, drugs, or chemicals, or it may be idiopathic. EAC-like eruptions have been described with nivolumab.[17]
Pertinent physical findings of EAC are usually limited to the skin, but a full physical examination should be conducted to assess for an underlying systemic process.[15] Therapy involves treating the underlying etiology.
Left and center images from Mandel VD et al. J Med Case Rep. 2015;9:236. PMID: 26496986. Right image from Wikimedia Commons | Mohammad2018). [Both images CC by-SA 4.0 International.]
10 Erythema Conditions You Should Know
Cristina Wojdylo | May 17, 2023 | Contributor Information
Skin findings of EAC
Primary lesion. The eruption begins as erythematous papules that spread peripherally while clearing centrally. These lesions enlarge at a rate of approximately 2-5 mm/d to produce annular, arcuate, figurate, circinate, or polycyclic plaques. The margin is usually indurated and varies in width from 4 to 6 mm; a trailing scale is often present on the inner aspect of the advancing edge. The diameter of the polycyclic lesions ranges from a few to several centimeters. Vesiculation may be present.
Distribution. Lesions demonstrate a predilection for the thighs and the legs (left image), but they may occur on the upper extremities (center images), the trunk (right image), or the face. The palms and the soles are spared.
Color. The lesions are pink to red with central clear areas. Occasionally, residual hyperpigmentation of dull red, brown, or violet is present.
Left image (leg) from Jmarchn; right image (abdomen) from James Heilman, MD. Both images via Wikimedia Commons. [Both images CC by-SA 3.0 Unported.]
10 Erythema Conditions You Should Know
Cristina Wojdylo | May 17, 2023 | Contributor Information
Erythema Ab Igne
Erythema ab igne (EAI) is characterized as localized areas of reticulated erythema and hyperpigmentation (shown) due to chronic and repeated exposure to infrared radiation.[18] Affected patients have a history of repeated exposures to heat at a lower level than that which causes a thermal burn.[19,20] Other terms used to describe this condition include toasted skin syndrome and fire stains.[21]
Initially, the skin in persons with EAI is often mildly erythematous; however, after repeated heat exposures, the classic blue, purple, or brown reticulated hyperpigmentation develops.[19]
No definitive therapy is available for EAI. Reducing or eliminating exposure to the heat source early in the EAI disease process may reverse the hyperpigmentation. In cases of short duration, complete resolution occurs with removal of the offending heating device. More advanced cases may respond somewhat to tretinoin, and 5-fluorouracil cream can help clear epithelial atypia.[22,23]
Image of palmar erythema in a patient with atopic dermatitis on the drug dupilumab courtesy of Neelesh Jain, MD.
10 Erythema Conditions You Should Know
Cristina Wojdylo | May 17, 2023 | Contributor Information
Palmar Erythema
Palmar erythema may be primary or secondary.[24] Primary palmar erythema is often hereditary or idiopathic. Over 30% of pregnant women have some degree of palmar erythema. Secondary palmar erythema is caused by an underlying disease process or some medications.
In adults, palmar erythema occurs in the setting of underlying liver disease, diabetes, thyrotoxicosis, rheumatoid arthritis, connective tissue diseases, neoplasms, and infections, as well as with certain drugs.[25] In children, it is most often a sign of Kawasaki or Wilson disease, poisoning, congenital syphilis, or hepatopulmonary hypertension.
The mechanism of action is thought to be due to alterations in the microvasculature of the palms resulting in vasodilation from estrogen, bradykinin, and other vasoactive modulators.[24,25] There is no treatment for primary palmar erythema. Therapy for secondary erythema involves treating the underlying etiology.
Image from Wikimedia Commons | Mohammad2018. [CC by-SA 4.0 International.]
10 Erythema Conditions You Should Know
Cristina Wojdylo | May 17, 2023 | Contributor Information
Erythema Toxicum Neonatorum
Erythema toxicum neonatorum is a benign self-limited eruption that occurs primarily in healthy newborns in the early neonatal period.[26] It is characterized by small papules or pustules surrounded by an erythematous wheal or macule,[27] typically appearing within the first 2-4 days of life in term neonates and resolving within the first 2 weeks of life.
The diagnosis of erythema toxicum neonatorum rests on recognizing the characteristic history and physical findings in an otherwise healthy newborn.[26] A complete history, physical examination, and Tzanck smear are required to differentiate between benign transient pustular eruptions of the newborn and life-threatening disease.
Cristina Wojdylo | May 17, 2023 | Contributor Information
Erythema Infectiosum (Fifth Disease)
Erythema infectiosum, also known as fifth disease, is usually a benign childhood condition characterized by a classic slapped-cheek appearance[28] and lacy exanthem.[29] It is caused by infection with human parvovirus B19, an erythrovirus.[30,31]
The diagnosis of erythema infectiosum is made on the basis of clinical presentation alone; a workup for patients with the classic presentation is not necessary.[28]
Because this condition is most often a benign, self-limited disease, the only intervention necessary is reassuring parents of affected children.[32] Symptomatic relief of erythema infectiosum may be provided with the use of nonsteroidal anti-inflammatory drugs to relieve fever, malaise, headache, and arthralgia, along with topical antipruritics and antihistamines (which also relieve pruritus). Treatment also includes plenty of fluids and rest.
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Contributor Information
Author
Cristina Wojdylo
Section Editor
Medscape Drugs & Diseases from WebMD
New York, NY
Cristina Wojdylo has disclosed no relevant financial
relationships.
Reviewer
Brett Sloan, MD, FAAD
Professor of Dermatology
University of Connecticut School of Medicine;
Dermatology Residency Program Director
Connecticut Veterans Affairs Healthcare System;
Editor-in-Chief
Journal of the American Academy of Dermatology Case Reports
Farmington, CT
Brett Sloan, MD, FAAD, has disclosed the following
relevant financial relationships:
Serve(d) as a director, officer, partner, employee, advisor,
consultant or trustee for: Journal of the American Academy of
Dermatology; UptoDate; Medical Review Institute of America.
Editor
Olivia Wong, DO
Section Editor
Medscape Drugs & Diseases
New York, NY
Olivia Wong, DO, has disclosed no relevant financial
relationships.
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References
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Nguyen GC, Torres EA, Regueiro M, et al. Inflammatory bowel disease characteristics among African Americans, Hispanics, and non-Hispanic Whites: characterization of a large North American cohort. Am J Gastroenterol. 2006 May;101(5):1012-23. PMID: 16696785
Sika-Paotonu D, Beaton A, Raghu A, Steer A, Carapetis J. Acute rheumatic fever and rheumatic heart disease. 2017 Mar 10 [updated 2017 Apr 3]. In: Ferretti JJ, Stevens DL, Fischetti VA, eds. Streptococcus pyogenes: Basic Biology to Clinical Manifestations [Internet]. Oklahoma City, OK: University of Oklahoma Health Sciences Center. 2016–. PMID: 28379675.
Centers for Disease Control and Prevention. Lyme disease. Signs and symptoms of untreated Lyme disease. Updated: January 15, 2021. Available at: https://www.cdc.gov/lyme/signs_symptoms/index.html. Accessed May 10, 2023.
Merrill JT, Buyon JP, Utset T. A 2014 update on the management of patients with systemic lupus erythematosus. Semin Arthritis Rheum. 2014 Oct;44(2):e1-2. PMID: 25437901
Firestein GS, Budd RC, Harris ED Jr, et al, eds. Kelley's Textbook of Rheumatology. 8th ed. Philadelphia, Pa: Saunders Elsevier; 2008.
Kuhn A, Landmann A. The classification and diagnosis of cutaneous lupus erythematosus. J Autoimmun. 2014 Feb-Mar;48-9:14-9. PMID: 24486120
McDaniel B, Cook C. Erythema annulare centrifugum. 2022 Aug 22. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; 2023 Jan–. PMID: 29494101
Sidiropoulou P, Sgontzou T, Kostara I, et al. Nivolumab in non-small cell lung cancer: a novel case of an erythema annulare centrifugum-like eruption. JAAD Case Rep. 2019 Jun 26;5(7):572-5. PMID: 31312704
Magro CM, Dawood MR, Crowson AN. The cutaneous manifestations of human parvovirus B19 infection. Hum Pathol. 2000 Apr;31(4):488-97. PMID: 10821497
Drago F, Ciccarese G, Broccolo F, Javor S, Parodi A. Atypical exanthems associated with Parvovirus B19 (B19V) infection in children and adults. J Med Virol. 2015 Nov;87(11):1981-4. PMID: 25965702
Macri A, Crane JS. Parvoviruses. 2022 May 23. StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; 2023 Jan–. PMID: 29489222
Revilla Grande AI, Carro García T, Sanchez de Dios M, Galan Calvo MJ, Nebreda Mayoral T. Brote de eritema infeccioso en un centro de salud urbano [Outbreak of infectious erythema at a urban health center] [Spanish, English]. Aten Primaria. 2000 Jul-Aug;26(3):172-5. PMID: 10996951
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