key: cord-0850964-drocjyjg
authors: Setó‐Torrent, N.; Altemir, A.; Iglesias‐Sancho, M.; Fernández‐Figueras, M.T.
title: Erythema annulare centrifugum triggered by SARS‐CoV‐2 infection
date: 2021-09-15
journal: J Eur Acad Dermatol Venereol
DOI: 10.1111/jdv.17645
sha: 961a37f6dae586c24d652072e9a917efae83fb57
doc_id: 850964
cord_uid: drocjyjg

Erythema annulare centrifugum (EAC) is a reactive phenomenon of the skin that has been reported to occur in association with numerous conditions, including infections.1 It commonly presents with annular, erythematous plaques with a fine desquamation in the inner portion of the advancing edge.2 In the last year, a wide spectrum of cutaneous manifestations has been associated with SARS-CoV-2 infection, including acral areas of erythema with vesicles or pustules, other vesicular eruptions, urticarial lesions, maculopapular eruptions and livedo or necrosis.3,4.

Erythema annulare centrifugum (EAC) is a reactive phenomenon of the skin that has been reported to occur in association with numerous conditions, including infections. 1 It commonly presents with annular, erythematous plaques with a fine desquamation in the inner portion of the advancing edge. 2 In the last year, a wide spectrum of cutaneous manifestations has been associated with SARS-CoV-2 infection, including acral areas of erythema with vesicles or pustules, other vesicular eruptions, urticarial lesions, maculopapular eruptions and livedo or necrosis. 3, 4 A 37-year-old otherwise healthy woman presented with a 1week history of itching skin lesions on the arms and back. She referred history of fever, headache and malaise 2 weeks before the onset of these lesions. A nasopharyngeal reverse transcription-polymerase chain reaction (RT-PCR) was positive for SARS-CoV-2 at that time. Physical examination revealed multiple erythematous papules and annular plaques with central clearing and a delicate scale on the inner margin on the upper arms and back ( Fig. 1 ). Potassium hydroxide test was negative. Histopathology showed a prominent perivascular lymphocytic infiltrate on papillary dermis and occasionally on reticular dermis, with endothelial tumefaction, hematic extravasation and sparse interstitial eosinophils (Fig. 2) . Clinicopathologic findings were compatible with EAC. A routine laboratory work-up had no alterations. Treatment with clobetasol propionate 0.05% cream was applied once daily for 2 weeks with completely resolution of the lesions.

EAC is a gyrate erythema characterized by erythematous papules that expand centrifugally with central clearing resulting in annular plaques. 2 Typically, a fine scale is present in the inner portion of the advancing edge, known as trailing scale. 2 Pruritus is variable, and the most frequent localizations are the trunk and lower extremities. 1 EAC is thought to be a delayed-type hypersensivity response to a wide variety of antigens. Possible triggers may include viral, bacterial or fungal infections, medications, foods, malignancy or other systemic diseases. 1,2,5 However, in many patients, a specific trigger cannot be recognized. 6 Histopathologic findings in EAC consist of a dense perivascular lymphocytic infiltrate on papillary dermis and possibly reticular dermis, which is known as a 'coat sleeve' appearance. Variable oedema, spongiosis, parakeratosis and basal layer vacuolization may be present. 1 Differential diagnosis includes other skin disorders that may present with annular, erythematous lesions such as erythema migrans, tinea, pityriasis rosea, psoriasis, granuloma annulare and annular lupus erythematosus. 1, 7 In our case, the typical clinic and histopathologic findings of EAC together with SARS-CoV-2 infection confirmed by a RT-PCR 2 weeks before supported the theory of a possible association. EAC has been suggested to be a tumour necrosis alpha (TNF-alpha) dependent process. 8 Therefore, the proinflammatory cytokines released during SARS-CoV-2 infection could be involved in the pathogenesis of EAC. 7 To our knowledge, there is only one previous report of EAC presumptive triggered by SARS-CoV-2. The patient presented with clinical and histopathological skin lesions consistent with EAC accompanied by anosmia and ageusia that completely resolved with doxycycline. 7 However, a RT-PCR was not obtained at that time and diagnosis of SARS-CoV-2 was made two months later based on a serological screening test. 7 Usually, EAC has a self-limited course and good prognosis. 2 Data on treatment for EAC are sparse. Topical corticosteroids, topical vitamin D analogues, metronidazole, macrolides (azithromycin, erythromycin), fluconazole and etanercept have been reported to be useful in some cases. 2, 7, 8 We report the second case of EAC probably triggered by SARS-CoV-2 in a patient with confirmed infection by nasopha-ryngeal RT-PCT 2 weeks before the onset of the cutaneous lesions that completely resolved with clobetasol propionate 0.05% cream.

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The patient in this manuscript has given written informed consent to publication of their case details.

All the authors declare no conflict of interest.

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