Erythema gyratum repens

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Synonyms and keywords: Gammel's disease.

Historical Perspective

• Erythema gyratum repens was first described by Dr. John A Gammel, the dermatologist, who was trained to link bizarre or recalcitrant dermatoses to internal diseases, In 1952, in a 55-year-old patient who had been complaining of pruritic scaly skin eruption and diagnosed nine months later with poorly differentiated adenocarcinoma of the breast with metastasis to axillary lymph nodes
• In 1950, Dr. Gammel presented his case before the Cleveland Dermatological Society as Erythema gyratum migrans then he changed the term to erythema gyratum repens because the eruption does not "migrate" from one place to another but "crawls" constantly in the areas involved, like ants on an anthill
• The association between cutaneous manifestations and systemic malignancies was first studied in 1925 by Rothman, the Hungarian investigative dermatologist, who wrote a comprehensive review on this subject and since then, cases were added to proof for the relationship between internal neoplasm and some skin lesions
• In 1973, 45 year old man was diagnosed with erythema gyratum repens associated with metastatic, undifferentiated adenocarcinoma which was removed following a right- sided craniotomy. The patient was misdiagnosed with erythema perstans and the malignancy was discovered after 8 months of the skin manifestations.
• Up to 1992, there were only 49 cases in the literature, 41 of which (84%) were associated with a neoplasm
• Between 1990 and 2010, a literature review was done by collecting data from the medical records of patients form dermatology department in University of Genoa and from databases as pubmed and medline, to conclude that erythema gyratum repens is no longer considered as an obligate paraneoplastic syndrome. More than expected cases of EGR were found with no neoplasm association

Classification

• Erythema gyratum repens has no established system for the classification. However, we can classify erythema gyratum repens based on its association with systemic malignancy as:
  • Paraneoplastic EGR
    • Erythema gyratum repens is associated with internal malignancy in 82% of cases
  • 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

Erythema Gyratum Repens classification
Paraneoplastic erythema gyratum repens
Non-paraneoplastic erythema gyratum repens
Idiopathic EGR
EGR-like eruptions
EGR with concomittant skin disease	pityriasis rubra pilaris, psoriasis, ichthyosis, CREST, rheumatoid arthritis, tuberculosis, bullous pemphigoid, linear IgA disease, and hypereosinophilic syndrome
Drug-induced EGR	Azathioprine with type I autoimmune hepatitis Interferon given for hepatitis C virus–related chronic hepatitis

Pathophysiology

• The pathogenesis of erythema gyratum repens is unclear
• Many immunologic theories have been implicated in its pathogenisis
• 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
• The gross appearance of the unique eruptions are annular, configurate, erythematous bands that form concentric rings, wood grain, scaly appearance
• The distinctive wood grain appearance of the eruption is pathogonomic
• The microscopic histologic features of erythema gratum repens are not characteristics but the following are the biopsy specimen findings that are compatible with the diagnosis:
  • Thin atrophic areas of the epidermis, with few parakeratotic horny layers.
  • The dermis contained a moderate perivascular lymphohistiocytic infiltrate as well as mild focal spongiosis and parakeratosis.
  • Diffuse to moderate edema of the connective tissue
  • Eosinophils and melanophages have also been reported in the dermal infiltrate

Causes

• The exact cause of EGR is unknown
• Various immunologic mechanisms suggest that EGR etiology is stemmed from an immunologic reaction.
• The association between erythema gyratum repens and systemic malignancy is evidenced by the disappearance of the pruritic eruptions after the treatment of the underlying neoplasm.
• The association doesn't necessarily mean causation.

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 associated with malignancy include:
    • Erythema annulare centrifugum (EAC)
    • Necrolytic migratory erythema (NME)
  • Reactive (figurate or gyrate) erythemas that are not associated with malignancy include:
    • Erythema marginatum rheumaticum
    • Erythema chronicum migrans   
    • Familial annular erythema
    • The carrier state of chronic granulomatous disease
    • Subacute cutaneous lupus erythematosus
    • Neonatal lupus erythematosus

Reactive (figurate or gyrate) erythemas with underlying malignancy

	Paraneoplastic syndrome?	Other associations	Skin lesions	Incidence & Demographics	Histopathology	Pathogenesis	Clinical symptoms	Lab finding    & Other evaluation	Treatment	Prognosis
Erythema gyratum repens (EGR)	84% Not obligatory Lung cancer     Esophageal cancer    Breast cancer Metastatic cancer with an unknown origin Cervical, stomach, and pharyngeal cancer (less common)	Tuberculosis CREST syndrome (calcinosis, Raynaud’s phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia).	Migratory annular and configurate erythematous bands that form concentric rings   Wood grain scaly appearance scale follows the leading edge of the bands Eruption migrates more rapidly, 1cm/d    Cover the trunk and proximal extremities, sparing the hands, feet, and face. Can eventually involve the face	Very rare Caucasian Male: female ratio is 2: 1 Average age was 62 years.	Nonspecific moderate perivascular lymphohistiocytic infiltrate    Mild focal spongiosis parakeratosis    Eosinophils and melanophages have also been reported in the dermal infiltrate	Not fully known but theories relate it to immunologic mechanisms.	Skin lesions, weight loss, fatigue, fever, and anorexia	No specific laboratory changes Eosinophilia has been reported Decreased T lymphocytes and increased B lymphocytes observed in an EGR patient with increased luteinizing hormone and follicle-stimulating hormone as well as decreased serum levels of C3    Normal percentages of B and T lymphocytes and normal T-cell function were reported in an EGR patient without cancer. Extensive evaluation for possible cancer CBC,CMP, imaging as CT chest or abdomen EGR patients with underlying malignancies had cancers associated with tobacco abuse.	Identification and treatment of the underlying condition (eg. resection of the tumor)	Skin manifestations can be improved within 48 hours of the resection of the underlying tumor The improvement sometimes can temporary with recurrence of the skin lesions specially in cases of metastasis Death can occur any time dending on the type and location of tumoe rnd the timingg f its discovery
Erythema annulare centrifugum (EAC)	Only a minority of patients   No particular type of cancer appears to predominate  Mutinous ovarian carcinoma    Bronchial carcinoma    Myeloma	Infections Allergic reactions to drugs	Migratory annular and configurate erythematous or polycyclic lesions Urticarial in appearance," ringed, arcuate figures" Eruption migrate at a slower rate (2 -3 mm/d) reaching up to 10 cm in diameter with central clearing. Cover only a small percentage of the total body surface	Uncommon but not rare No tendency for EAC to favor any age, race, or sex.	Deep form: Mononuclear, perivascular infiltrate in the middle and lower portions of the dermis (coat sleeve-like configuration) Infiltrate is 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			No specific laboratory changes 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    Evaluation for possible infection or drug reaction (prescribed and non-prescribed) complete blood count, urinalysis, and routine serum liver and kidney function tests.	Identification and treatment of the underlying condition (eg. resection of the tumor)	Lesions disaapears after the underlying etiology is managed (allergy, infection, malignancy) if no underlying cause, lesions can recur after discontinuation of the supportive treatment.
Necrolytic migratory erythema (NME)	Obligatory paraneoplastic syndrome (2) The first presenting symptom in 70% of patients with glucagonoma syndrome (2) NME is the hallmark of glucagonoma (pancreatic neuroendocrine tumors (PNETs) (glucagonoma) (3)	No other association but it can be misdiagnosed as contact dermatitis or intertrigo, inverse psoriasis, zinc deficiency, and other nutritional deficiencies	migratory circinate erythema/plaques with areas of necrosis and sloughing (3) Crusted  Erythematous scaly plaques with centrifugal growth Spontaneous exacerbation and remission periods without knowing what the trigger is Perineum, distal extremities, lower abdomen, and face are the most commonly affected sites.	Rare Only 2,705 cases in the US of pancreatic neuroendocrine tumors in a period of 28 years with glucagonomas Only 1.3% of these neoplasms Combined with glucagonoma syndrome An estimated global incidence of 1 case per 20 million people (3)	Paleness and spongiosis of the upper layer of the epidermis. A perivascular lymphocytic and histiocytic infiltrate Necrotic keratinocytes are common and can lead to erosions, crusting and scaling	Not fully clarified but attributed to zinc deficiency and hypoaminoacedemia as Increased glucagon increases gluconeogesis. Although NME can be the first symptom of glucagonoma, high glucagon levels can't explain the skin manifestations.	Weight loss, anemia, diabetes, diarrhea, and stomatitis.	increased glucagon level (3) Evaluation of the associated tumor: CT or MRI abdomen Selective visceral angiography to localize the tumor Positron Emission tomography (PET) Octreotide scintigraphy	Identification and treatment of the underlying condition (eg. resection of the tumor)	Due to the difficulty of NME recognition, and its association with glucagonoma, diagnosis is usually delayed(3) NME usually resolved after the resection and treatment of the pancreatic tumor, eg 10 days after tumor resection Early recognition is crucial for better diagnosis

Epidemiology and Demographics

• EGR is a rare dermatologic disease, usually associated with paraneoplastic neoplasm

Age

• The average age of onset of EGR is in the seventh decade of life (65 years old)

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
• If the underlying malignancy left untreated, the debilitating pruritus could persist until the patient dies
• Prognosis depends on the type of the underlying tumor and the probability of its treatment. It depends on the time of the EGR onset and the neoplasm discovery. The course and prognosis of EGR can be one of the following:
  • Complete cure of the skin eruption and pruritus after removal and treatment of the internal neoplasm
  • Temporary improvement then recurrence of the eruption (specially in cases of metastasis)
  • No effect of the tumor treatment on the course of EGR
  • Death can occur few weeks after the discovery of the malignancy, few months, or four years as in Gammel's patient.

Diagnosis

Diagnostic Study of Choice

• EGR is mainly diagnosed clinically by its characteristic skin lesions.
• It is considered as a cutaneous marker of malignancy with high specificity so physicians shouldn't miss its unique clinical skin presentation.

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
  • Many patients with EGR and malignancy had a history of tobacco smoking
  • some patients with EGR and malignancy have a family history of neoplasm

Physical Examination

• Patients with EGR can be ill-appearing and lethargic
• Thorough physical exam should be done to look for signs of malignancy as lymph node enlargements, mass, abdominal distension, shortness of breath, pleural effusion,or papilloedema.
• The 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

Laboratory Findings

• There are no diagnostic laboratory findings associated with EGR.
• Eosinophilia is observed in 60% of cases
• Evaluation to exclude systemic involvement:
  • CBC, CMP, urine analysis, LFT, guaiac stool test, serum protein electrophoresis

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
• 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
• 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
• 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].