Approach to the patient with annular skin lesions
- Rashmi Unwala, MD
Rashmi Unwala, MD
- Assistant Professor of Medicine - Department of Dermatology
- College of Medicine, Mayo Clinic
A wide variety of cutaneous and systemic disorders present with annular (ring-like) skin lesions (table 1). The careful assessment of lesion characteristics and accompanying clinical features is valuable for narrowing the differential diagnosis.
Diagnostic clues for the identification of disorders that present with annular lesions will be reviewed here. Greater detail on many of the disorders discussed below is available elsewhere in UpToDate.
Annular skin lesions are figurate lesions characterized by a ring-like morphology. Although plaques represent the most common presentation of annular lesions, lesions may also be macular, nodular, or composed of grouped papules, vesicles, or pustules.
Additional terms that are frequently used to describe the characteristics of annular lesions include:
●Arcuate – Consists of arc-shaped lesions that represent incompletely formed annular lesions (picture 1)
- Sakakibara K, Nakada T, Sueki H, et al. Annular lichen planus. J Cutan Med Surg 2004; 8:173.
- Ponce-Olivera RM, Tirado-Sánchez A, Montes-de-Oca-Sánchez G, et al. Annular atrophic lichen planus. Int J Dermatol 2007; 46:490.
- Weyers W, Diaz-Cascajo C, Weyers I. Erythema annulare centrifugum: results of a clinicopathologic study of 73 patients. Am J Dermatopathol 2003; 25:451.
- Ho JC, Ng PL, Tan SH, Giam YC. Childhood linear IgA bullous disease triggered by amoxicillin-clavulanic acid. Pediatr Dermatol 2007; 24:E40.
- Hoesly FJ, Huerter CJ, Shehan JM. Purpura annularis telangiectodes of Majocchi: case report and review of the literature. Int J Dermatol 2009; 48:1129.
- AlSufyani MA. Acute hemorrhagic edema of infancy: unusual scarring and review of the English language literature. Int J Dermatol 2009; 48:617.
- Peroni A, Colato C, Zanoni G, Girolomoni G. Urticarial lesions: if not urticaria, what else? The differential diagnosis of urticaria: part II. Systemic diseases. J Am Acad Dermatol 2010; 62:557.
- Wormser GP. Clinical practice. Early Lyme disease. N Engl J Med 2006; 354:2794.
- Katta R, Anusuri V. Serum sickness-like reaction to cefuroxime: a case report and review of the literature. J Drugs Dermatol 2007; 6:747.
- Starnes L, Patel T, Skinner RB. Urticaria multiforme--a case report. Pediatr Dermatol 2011; 28:436.
- Shah KN, Honig PJ, Yan AC. "Urticaria multiforme": a case series and review of acute annular urticarial hypersensitivity syndromes in children. Pediatrics 2007; 119:e1177.
- Prajapati V, Cheung-Lee M, Schloss E, Salopek TG. Spontaneously resolving eosinophilic annular erythema. J Am Acad Dermatol 2012; 67:e75.
- El-Khalawany M, Al-Mutairi N, Sultan M, Shaaban D. Eosinophilic annular erythema is a peculiar subtype in the spectrum of Wells syndrome: a multicentre long-term follow-up study. J Eur Acad Dermatol Venereol 2013; 27:973.
- Sempau L, Larralde M, Luna PC, et al. Eosinophilic annular erythema. Dermatol Online J 2012; 18:8.
- Rongioletti F, Fausti V, Kempf W, et al. Eosinophilic annular erythema: an expression of the clinical and pathological polymorphism of Wells syndrome. J Am Acad Dermatol 2011; 65:e135.
- Obermoser G, Sontheimer RD, Zelger B. Overview of common, rare and atypical manifestations of cutaneous lupus erythematosus and histopathological correlates. Lupus 2010; 19:1050.
- Meads SB, Kunishige J, Ramos-Caro FA, Hassanein AM. Lichen planus actinicus. Cutis 2003; 72:377.
- Kim GH, Mikkilineni R. Lichen planus actinicus. Dermatol Online J 2007; 13:13.
- Wetter DA, Davis MD. Recurrent erythema multiforme: clinical characteristics, etiologic associations, and treatment in a series of 48 patients at Mayo Clinic, 2000 to 2007. J Am Acad Dermatol 2010; 62:45.
- Serrão VV, Organ V, Pereira L, et al. Annular lichen planus in association with Crohn disease. Dermatol Online J 2008; 14:5.
- Annessi G, Paradisi M, Angelo C, et al. Annular lichenoid dermatitis of youth. J Am Acad Dermatol 2003; 49:1029.
- Halpern J, Salim A. Pediatric sweet syndrome: case report and literature review. Pediatr Dermatol 2009; 26:452.
- Ming A, Wargon O. Annular lesions in Kawasaki disease: a cause of confusion. Australas J Dermatol 2008; 49:207.
- Torrelo A, Patel S, Colmenero I, et al. Chronic atypical neutrophilic dermatosis with lipodystrophy and elevated temperature (CANDLE) syndrome. J Am Acad Dermatol 2010; 62:489.
- PATIENT ASSESSMENT
- Lesion characteristics
- - Color
- - Scale
- - Vesicles or pustules
- - Purpura
- Lesion progression
- - Expanding lesions
- - Migratory lesions
- Lesion location
- - Photodistributed
- - Acral
- - Genital
- FEBRILE PATIENTS
- DIAGNOSTIC TESTS
- Skin biopsy
- EMPIRICAL DIAGNOSIS OF TINEA CORPORIS
- INDICATIONS FOR REFERRAL
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS