Erythema gyratum repens: Difference between revisions
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** Theory 1 the tumor induces antibodies that cross-react with the basement membrane of skin | ** Theory 1 the tumor induces antibodies that cross-react with the basement membrane of skin | ||
** Theory 2 the tumor produces polypeptides that bind skin antigens and render them immunogenic | ** Theory 2 the tumor produces polypeptides that bind skin antigens and render them immunogenic | ||
** Theory 3 deposition of tumor antigen-antibody complexes onto the basement membrane causes | ** Theory 3 deposition of tumor antigen-antibody complexes onto the basement membrane causes reactive dermatitis seen in EGR | ||
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==Causes== | ==Causes== | ||
* The cause of erythema gyratum repens has not been identified. | * The cause of erythema gyratum repens has not been identified. | ||
* Different theories suggest that EGR etiology is stemmed from immunologic reaction | * Different theories suggest that EGR etiology is stemmed from an immunologic reaction | ||
==Differentiating Erythema Gyratum Repens from Other Diseases== | ==Differentiating Erythema Gyratum Repens from Other Diseases== | ||
*EGR has a narrow differential diagnosis | *EGR has a narrow differential diagnosis. It has to be differentiated from Reactive gyrate erythematous eruptions, such as: | ||
** Necrolytic migratory erythema (NME) | ** Reactive (figurate or gyrate) erythemas that are not associated with malignancy include: | ||
** Erythema annulare centrifugum (EAC) | *** Necrolytic migratory erythema (NME) | ||
** Erythema chronicum migrans | *** Erythema annulare centrifugum (EAC) | ||
* Reactive (figurate or gyrate) erythemas that are not associated with malignancy include | *** Erythema chronicum migrans | ||
* Erythema marginatum rheumaticum | ** Reactive (figurate or gyrate) erythemas that are not associated with malignancy include: | ||
* familial annular erythema | *** Erythema marginatum rheumaticum | ||
* the carrier state of chronic granulomatous disease | *** familial annular erythema | ||
* subacute cutaneous lupus erythematosus | *** the carrier state of chronic granulomatous disease | ||
* neonatal lupus erythematosus, and | *** subacute cutaneous lupus erythematosus | ||
* erythema marginatum | *** neonatal lupus erythematosus, and | ||
*** erythema marginatum rheumaticum | |||
{| class="wikitable" | {| class="wikitable" | ||
Revision as of 20:17, 21 June 2019
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Synonyms and keywords: Gammel's disease.
Overview
Historical Perspective
- In 1925 Rothman wrote a comprehensive review on the subject of cutaneous manifestations in patients with malignant tumors and since then cases were added to proof for the relationship between internal neoplasm and some skin lesions.
- In 1953, the dermatologist, Dr. John A Gammel who was trained to link bizarre or recalcitrant dermatoses to internal diseases was the first one who described and labeled Erythema Granulatum Repens in a 55-year-old patient who had been complaining of pruritic scaly skin eruption and found few months later to have poorly differentiated adenocarcinoma.
- Up to 1992, there were only 49 cases in the literature, 41 of which (84%) were associated with a neoplasm
- EGR is associated with internal malignancy in 82% of cases. However, between 1990 and 2010, data was collected from the medical records of patients form dermatology department in University of Genoa and from databases as pubmed and medline, the conclusion of this literature review was that EGR is no longer considered as an obligate paraneoplastic syndrome. More than expected cases of EGR were found with no neoplasm association
- Non-paraneoplastic EGR could be:
- Idiopathic EGR
- EGR-like eruptions (different dermatologic lesions that mimic EGR)
- EGR with concomittant skin disease as:
- pityriasis rubra pilaris, psoriasis, ichthyosis, CREST, rheumatoid arthritis, tuberculosis, bullous pemphigoid, linear IgA disease, and hypereosinophilic syndrome
- Drug-induced EGR examples are:
- Azathioprine with type I autoimmune hepatitis
- Interferon given for hepatitis C virus–related chronic hepatitis
Classification
- There is no established system for the classification of EGR.
Pathophysiology
- The cause of EGR has not been identified.
- Many theories suggest that EGR is due to immunologic mechanisms
- The immunologic mechanism theory is evidenced by the observed immunofluorescence patterns of IgG, C3, and C4 at the basement membrane:
- Theory 1 the tumor induces antibodies that cross-react with the basement membrane of skin
- Theory 2 the tumor produces polypeptides that bind skin antigens and render them immunogenic
- Theory 3 deposition of tumor antigen-antibody complexes onto the basement membrane causes reactive dermatitis seen in EGR
Causes
- The cause of erythema gyratum repens has not been identified.
- Different theories suggest that EGR etiology is stemmed from an immunologic reaction
Differentiating Erythema Gyratum Repens from Other Diseases
- EGR has a narrow differential diagnosis. It has to be differentiated from Reactive gyrate erythematous eruptions, such as:
- Reactive (figurate or gyrate) erythemas that are not associated with malignancy include:
- Necrolytic migratory erythema (NME)
- Erythema annulare centrifugum (EAC)
- Erythema chronicum migrans
- Reactive (figurate or gyrate) erythemas that are not associated with malignancy include:
- Erythema marginatum rheumaticum
- familial annular erythema
- the carrier state of chronic granulomatous disease
- subacute cutaneous lupus erythematosus
- neonatal lupus erythematosus, and
- erythema marginatum rheumaticum
- Reactive (figurate or gyrate) erythemas that are not associated with malignancy include:
| EGR | EAC | ACM | EMR | |
|---|---|---|---|---|
| Reactive erythema (figurate or Gyrate) | Yes | Yes | Yes | |
| Associated malignancy? | more closely associated (84%) | only a minority of patients | Mainly gluconoma | |
| Most common associated neoplasm | lung cancer
esophageal cancer Breast cancer metastatic cancer with an unknown origion Cervical, stomach, and pharyngeal cancer (less common) |
no particular type of cancer appears to predominate
mutinous ovarian carcinoma bronchial carcinoma myeloma |
||
| Other association | tuberculosis
CREST syndrome (calcinosis, Raynaud’s phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia). |
infections and allergic reactions to drugs | ||
| Skin lesion description | migratory annular and configurate erythematous bands
that form concentric rings Wood grain scaly appearance scale follows the leading edge of the bands. cover the trunk and proximal extremities, sparing the hands, feet, and face. Eruption migrates more rapidly, 1cm/d |
migratory annular and configurate
annular or polycyclic lesions which may begin as urticaria-like papules Urticarial in appearance ringed, arcuate figures erythematous lesions cover only a small percentage of the total body surface migrate at a slower rate (2 -3 mm/d) reaching up to 10 cm in diameter and resulting in central clearing. |
||
| First named by | Gammel in 1952 | Darier 1916 |
||
| Incidence | Very rare | uncommon but not rare | ||
| Demographics | Caucasian
male: female ratio is 2: 1 average age was 62 years. |
no tendency for EAC to favor any age, race, or sex. | ||
| Subgroups | Deep: Firm border, rarely pruritic, no scales
Superficial: indistinct scaly border , usually pruritic, |
|||
| Histopathology | Nonspecific
moderate perivascular lymphohistiocytic infiltrate mild focal spongiosis parakeratosis Eosinophils and melanophages have also been reported in the dermal infiltrate |
deep form
mononuclear, perivascular infiltrate is present in the middle and lower portions of the dermis (coat sleeve-like configuration) infiltrate is usually composed primarily of lymphocytes, but eosinophils are occasionally present Extravasation of erythrocytes is associated with endothelial swelling no epidermal changes superficial more non-specific slight superficial perivascular lymphohistiocytic infiltrate focal parakeratosis and mild spongiosis with microvesiculation |
||
| Lab finding |
Eosinophilia has been reported
were observed in an EGR patient with increased luteinizing hormone and follicle-stimulating hormone as well as decreased serum levels of C3
|
Eosinophilia of the peripheral blood, as well as tissue, can be observed in EAC associated with a drug reaction or parasitic infection Decreased T lymphocytes and increased B lymphocytes |
||
| Extensive evaluation for possible cancer
|
Evaluation for possible infection or drug reaction (prescribed and non-prescribed)
complete blood count, urinalysis, and routine serum liver and kidney function tests. |
|||
| Treatment |
|
identification and treatment of the underlying condition, as the course of either eruption usually parallels that of the underlying process. | ||
| Symptomatic therapy as antihistamine and corticosteroids | systemic corticosteroids for the deep form and topical corticosteroids for the superficial form
Lesions of EAC, however, frequently recur following discontinuation of such treatment |
|||
Epidemiology and Demographics
- EGR is a rare dermatologic disease, usually associated with paraneoplastic neoplasm [1]
Age
- The average age of onset of EGR is in the seventh decade of life
Gender
- The male to female ratio is 2:1
Race
- EGR commonly affects Caucasians
Risk Factors
- There are no established risk factors for EGR
Screening
- There are no screening tests for EGR.
- Screening for internal malignancy should be done immediately after EGR is diagnosed.
Natural History, Complications, and Prognosis
- The majority of patients with EGR presents with severely pruritic erythematous skin lesions that appear several months prior to the malignancy diagnosis [1]
- If the underlying malignancy left untreated, the debilitating pruritus could persist until the patient dies [1]
- Prognosis depends on the type of the underlying tumor and the probability of its treatment.
Diagnosis
Diagnostic Study of Choice
- EGR is mainly diagnosed clinically by its characteristic skin lesions.
History and Symptoms
- The universal symptoms of EGR are:
- Skin eruptions
- Intense pruritus
- Other symptoms related to the associated internal malignancy are:
- Weight loss
- Anorexia
- Fatigue
- Fever
Physical Examination
- Patients with EGR presents with a rash consisting of wavy erythematous concentric bands that can be figurate, gyrate, or annular.
- The bands are arranged in parallel rings and lined by a fine trailing edge of scale, a pattern often described as “wood grained.
- The rash typically involves large areas of the body but tends to spare the face, hands, and feet and it can expand as fast as a cm a day.
- Bullae can also form from within the areas of erythema [1]
Laboratory Findings
- There are no diagnostic laboratory findings associated with EGR.
- Eosinophilia is observed in 60% of cases [1]
Imaging Findings
- There are no imaging findings associated with EGR.
- Imaging of the chest and abdomen could show malignancy findings.
Other Diagnostic Studies
- Direct immunofluorescence in some cases shows patterns of IgG, C3, and C4 at the basement membrane [1]
- The histopathologic features of EGR is non-specific.
- Biopsy specimens show the following:
- Acanthosis, mild hyperkeratosis, focal parakeratosis, and spongiosis confined to the epidermis and superficial dermis.
- Mononuclear, lymphocytic, and histiocytic perivascular infiltrate in the superficial plexus can also be seen [1]
- Thorough paraneoplastic workup includes:
- Computed tomography of thorax, abdomen, and pelvis
- Positron emission tomography/computed tomography
- Upper and lower gastrointestinal endoscopy
- Tumor markers
- Blood tests including lactate dehydrogenase and QuantiFERON to exclude tuberculosis.
Treatment
Medical Therapy
- There is no treatment for EGR; the mainstay of therapy is supportive care and treating the underlying condition [1]
- Various dermatologic and immunosuppressive therapies have been used to treat EGR.
- Systemic steroids are frequently ineffective.
- Topical steroids, vitamin A, and azathioprine have also failed to relieve skin manifestations.
- Improvement of EGR, and its associated intense pruritus depends on recognition and treatment of the underlying malignancy.
- Chemotherapy can be used to treat the internal malignancy.
Surgery
- Surgical resection of the internal tumor could be recommended as part of the management of EGR.
Prevention
- There are no primary preventive measures available for [disease name].