Erythema may be of toxic-allergic origin

Among the so-called persistent erythema, in terms of frequency and known clinical features, Darier's erythema occupies the main place - a disease that looks like an abnormal reddening of the skin and is caused by an excessive rush of blood to the skin capillaries. This disease has been aptly named "centrifugal annular erythema", as it is represented by pinkish spots, which, developing centrifugally, turn around the periphery into formations in the form of rings up to 3-5 cm in diameter.

Erythema annular centrifugal Darier is often associated with the development of neoplasms and with diseases of the blood or hematopoietic organs, since diagnostic studies usually detect IgG in the basement membrane zone, which may mean a toxic-allergic origin of the rashes.

Patient A., 53 years old. The debut of the disease happened six months ago, when two pinkish-red foci of rounded outlines appeared in the region of the right shoulder, tending to peripheral growth with the formation of an inflammatory edematous ridge along the periphery.

Complaints: disturbed by rashes, accompanied by moderate itching, periodically occurring for no reason on the limbs and trunk. The elements of the rash changed color within two weeks: they acquired a brownish hue, swelling resolved, itching regressed. The disease recurred every tenth day of the month, proceeded cyclically. The number of loose elements, which were resolved independently, increased. The general health of the patient did not suffer.

From the anamnesis it is known that the patient suffered from peptic ulcer of the duodenum eight years ago. Currently in remission. The climax is observed for three years. The patient does not notice any general changes.

Physical research. On the skin of the trunk, chest, upper limbs and thighs, there are numerous foci, represented by non-scaly pinkish spots resembling urticarial erythema. Rapidly developing centrifugally up to 3-5 cm in diameter, turning along the periphery into dense roller-like formations in the form of scallops and rings, in the center they form a barely noticeable transient pigmentation. Moderate itching is subjectively disturbing.

EGDS: erosive gastritis with signs of atrophy. Ultrasound of the thyroid gland, abdominal organs and small pelvis without features. Clinical and biochemical blood and urine tests were within normal limits. In the hormonal profile of the gastropanel, including the study of gastrin-17 basal, gastrin-17 stimulated, pepsinogen-1, pepsinogen-11, antibodies (AT) to Helicobacter pylori, an increase in the levels of pepsinogen-1 was noted (167.48 at a rate of > 120 mg% ), pepsinogen-11 (31.29 at a rate of > 10 mg) and Helicobacter pylori AT IgG (1.1 at a rate of > 0.9).

A biopsy of the lesion in the back was made: the epidermis of the usual type, in the superficial layers of the skin itself, clearly defined non-specific lymphoid infiltrates located perivascularly are determined.

Conclusion: erythema annulare.

Diagnosis: Darier's annular centrifugal erythema.

Discussion. Among the so-called "persistent erythema" in terms of frequency and known clinical features, the main place is occupied by Darier's erythema, described by the author in 1916, when the disease was first given the apt name "centrifugal annular erythema".

Etiopathogenesis has not been established. Assume infectious and toxic-allergic nature of the disease. Evidence of immune genesis is the detection of IgG in the basement membrane zone. Clinical descriptions are not uncommon, indicating a combination of Darier's erythema with tumors and hemopathy. Familial cases are known. Both sexes are affected, more often than men. Sometimes the disease occurs in children. The average duration of the disease is about 3 years.

Clinic. Primary efflorescences are represented by non-scaly yellowish-pink spots, resembling urticarial erythema, rapidly forming into dense annular formations, presented in the form of arcs, segments, and rings along the periphery. The central part of the foci tends to resolve, where the phenomena of barely noticeable pigmentation are revealed. It should be noted a sign characteristic of this type of erythema: the growth of rashes along the periphery, which Darier excellently shaded in the name of this process - "centrifugal". In addition, the acute development of each rash is necessarily detected in the chronic course of the process as a whole. The favorite localization of the elements is the trunk, thighs, proximal parts of the limbs, less often - skin areas on the hands and feet. Subjective sensations may be absent or manifest as tolerable itching,

In foreign literature, superficial and deep types of erythema are considered. The surface type is distinguished by the absence of clear boundaries of spots, their outline. Desquamation is detected along the periphery of the foci, the presence of itching. The deep type is characterized by pronounced edematous ridge-like edges of the rash, the absence of peeling and itching.

The following forms belong to atypical varieties of Darier's erythema. Peeling erythema Darier, in which there is peeling of the outer edge of the foci. Otherwise, typical clinical signs of Darier's erythema are present. Vesicular erythema Darier is characterized by the classic centrifugal development of erythematous lesions and is accompanied by rapidly transient vesicular elements along the edges, where edematous inflammatory ridges are noted. Simple garland-like erythema of Yadasson differs from the typical cyclic course of individual rashes that exist for only a few days, but the process itself is long-term. Persistent microgarland-like erythema is characterized by a small size of individual elements of the rash (up to 1 cm in diameter). Rashes without changing can exist for several months. Of the rarest, induced and telangiectatic-purple forms of Darier's erythema are distinguished. The general condition of patients with erythema Darya and its varieties does not suffer.

Histopathology. There are no specific changes in the epidermis and dermis. In the epidermis - acanthosis, parakeratosis, spongiosis, rarely vesiculation. With a superficial type in the dermis - a perivascular infiltrate of histiocytes, lymphocytes, sometimes with an admixture of eosinophils and neutrophils, swelling of the papillary layer of the skin; with a deep type, the infiltrate captures both the superficial and deep vascular network. Changes in the epidermis and swelling of the papillary layer are rare.

Differential diagnosis is Gammel's garland erythema migrans, Wende's persistent curly erythema, exudative erythema multiforme, Lipschütz's erythema migrans (boreliosis), Lendorf-Leiner's rheumatic erythema, Lendorf-Leiner's rheumatic erythema, dermatophytosis, Gibert's atypical pink lichen.

Treatment involves sanitation of foci of focal infection, therapy of comorbid conditions. The use of antipruritics and corticosteroid ointments is preferred.

In the case under discussion, the diagnosis was based on biopsy data, anamnesis and the results of studies of the gastrointestinal tract, where at the moment the main, apparently, underlying factors that contribute to the formation of this process are being identified. The patient needs to be monitored by a gastroenterologist and a dermatologist. Local therapy with clobetasol against the background of the use of the drug normospectrum allowed to resolve the rash, but did not completely prevent the appearance of new elements.