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225J UOEH 34（ 3 ）: 225－229（2012）
［Case Report］
Erythema Annulare Centrifugum Associated with Herpes Zoster
Shun Ohmori1, Kazunari Sugita1, Atsuko Ikenouchi-Sugita2 and Motonobu Nakamura1
1 Department of Dermatology, School of Medicine, University of Occupational and Environmental Health, Japan. Yahatanishi-ku, Kitakyushu 807-8555, Japan
2 Department of Psychiatry, School of Medicine, University of Occupational and Environmental Health, Japan. Yahatanishi-ku, Kitakyushu 807-8555, Japan
Abstract : Erythema annulare centrifugum (EAC) presents as erythematous or urticarial papules, each with an annular shape, that exhibit peripheral extension. Internal malignancies are occasionally associated with EAC, and infectious diseases, including fungal, bacterial or viral infections, have also been regarded as possible causes of EAC. A 35-year old man had a 1-week history of a painful vesicular eruption over the trunk corresponding to dermatomes Th8-10. Concomitantly, he developed several annular eruptions over the trunk. We diagnosed the former lesions as herpes zoster and the latter as EAC associated with herpes zoster. Although DNA was extracted from the EAC region, no varicella-zoster virus DNA was detected. We consider that this is Wolf’s isotopic response, which is caused by an alteration of the local immunity due to viral infection. An etiologic relationship between EAC and herpes zoster is strongly suggested by the present case and by our review.
Key words : erythema annulare centrifugum, herpes zoster, Wolf’s isotopic response.
（Received April 24, 2012, accepted July 6, 2012）
Introduction
Erythema annulare centrifugum (EAC) presents as erythematous or urticarial papules, each with an annular shape, that exhibit peripheral extension. Clinically, EAC can be divided into two types: deep gyrate erythema, which is characterized by a firm, indurated border, no scales, and rare pruritus, and superficial gyrate erythema, which has an indistinct border with trailing scales and pruritus [1]. Internal malignancies are occasionally associated with EAC, and infectious dis-eases, including fungal, bacterial or viral infections, have also been regarded as possible causes of EAC [1]. We have previously reported a case of EAC that occurred in association with herpes zoster [2]. Here we report another case of herpes zoster-associated EAC, and review the litera-ture on this subject.
227EAC Associated with Herpes Zoster
Discussion
EAC occasionally occurs as a hypersensitivity reaction to various infectious diseases, and herpes zoster is thought to be one of the causative agents [2, 3]. VZV DNA was not found in the skin region of the present case, suggesting that the EAC took place not as a direct consequence of local VZV infection, but through some immune reaction to the VZV. In Table 1, we summarize the clinical characteristics of four cases of herpes zoster-associated EAC [2, 3]. The mean age at diagnosis was 40.8 years, ranging from 33 to 59 years; cases were most likely to occur in healthy young men. The time interval between the onset of EAC and that of herpes zoster eruption was inconsistent. Although EAC occurs most frequently (in 48% of cases) on the lower extremities [1], all the cases in this review developed herpes zoster on the thoracic dermatomes, and annular
Fig. 2. Histopathological findings. Superficial perivascular lymphocytic infiltrations were noted.
Tabl e 1. Repor t ed cases of EAC associat ed wit h her pes zost erCase Age
(years/sex)Past diseases
Time interval between EAC and herpes zoster
Dermatomes of herpes zoster
Sites of EAC Treatment for EAC Clinical course
Reference
1 36/M － 1 month Th 6-7 (left) Same as herpes zoster
Topical corticosteroid, oral antihistamine
Improved 3
2 33/F － 2 weeks Th 4-6 (right) Same as herpes zoster
Topical corticosteroid, oral corticosteroid, oral antihistamine
Improved 3
3 59/M － 9 days Th 6-7 (left) In conjunction with herpes zoster, other areas of trunk and shoulders
Topical corticosteroid
Improved 2
4 35/M － 0 day Th 8-10 (both sides) Chest and abdomen None Improved This case
EAC: Eryt hema annul ar e cent r ifugum
226 S Ohmori et al
Case Report
A 35-year old Japanese man presented in March 2011 with a 1-week history of a painful vesic-ular eruption over the trunk corresponding to dermatomes Th8-10. Concomitantly, he developed several new erythematous, marginally indurated eruptions over the trunk (Fig. 1A-C). He was otherwise healthy. Skin biopsy showed mild perivascular lymphocytic infiltration without any epidermal ballooning degeneration (Fig. 2). DNA was extracted from the biopsy specimen and was subjected to real-time PCR; however, no varicella-zoster virus (VZV) DNA was detected in the EAC region. Intriguingly, after five days of treatment with valacyclovir, the annular erup-tions as well as the vesicular eruptions resolved almost completely.
A B
C
Fig. 1. Clinical appearance of herpes zoster and erythema annulare centrifugum. A, B: Annular ery-thematous eruptions on the areas corresponding to herpes zoster infection. Arrows show the annular eruptions and arrowheads show vesicular eruptions. C: Close-up photography of annular eruption.
227EAC Associated with Herpes Zoster
Discussion
EAC occasionally occurs as a hypersensitivity reaction to various infectious diseases, and herpes zoster is thought to be one of the causative agents [2, 3]. VZV DNA was not found in the skin region of the present case, suggesting that the EAC took place not as a direct consequence of local VZV infection, but through some immune reaction to the VZV. In Table 1, we summarize the clinical characteristics of four cases of herpes zoster-associated EAC [2, 3]. The mean age at diagnosis was 40.8 years, ranging from 33 to 59 years; cases were most likely to occur in healthy young men. The time interval between the onset of EAC and that of herpes zoster eruption was inconsistent. Although EAC occurs most frequently (in 48% of cases) on the lower extremities [1], all the cases in this review developed herpes zoster on the thoracic dermatomes, and annular
Fig. 2. Histopathological findings. Superficial perivascular lymphocytic infiltrations were noted.
Tabl e 1. Repor t ed cases of EAC associat ed wit h her pes zost erCase Age
(years/sex)Past diseases
Time interval between EAC and herpes zoster
Dermatomes of herpes zoster
Sites of EAC Treatment for EAC Clinical course
Reference
1 36/M － 1 month Th 6-7 (left) Same as herpes zoster
Topical corticosteroid, oral antihistamine
Improved 3
2 33/F － 2 weeks Th 4-6 (right) Same as herpes zoster
Topical corticosteroid, oral corticosteroid, oral antihistamine
Improved 3
3 59/M － 9 days Th 6-7 (left) In conjunction with herpes zoster, other areas of trunk and shoulders
Topical corticosteroid
Improved 2
4 35/M － 0 day Th 8-10 (both sides) Chest and abdomen None Improved This case
EAC: Eryt hema annul ar e cent r ifugum
229EAC Associated with Herpes Zoster
帯状疱疹に関連した遠心性環状紅斑の1例
大森 俊1，杉田 和成1，杉田 篤子2，中村 元信1
1 産業医科大学 医学部 皮膚科学教室2 産業医科大学 医学部 精神医学教室
要 旨：遠心性環状紅斑は隆起性の紅斑や蕁麻疹様丘疹が遠心性に周囲へ拡大し，輪状ないし環状の形態を呈する．しばしば内臓悪性腫瘍に関連して発症することがあり，また真菌，細菌，ウイルス感染も遠心性環状紅斑の誘因になるとされている．症例は35歳の男性で，1週間前より体幹部（皮膚分節Th8-10）に疼痛を伴う水疱を自覚していた．それに付随して，体幹部には複数の環状紅斑も出現していた．前者の皮疹を帯状疱疹，後者を遠心性環状紅斑と診断した．環状紅斑の病変部よりDNAを抽出するも，水痘帯状疱疹ウイルスのDNAは検出されなかった．したがってこの環状紅斑は，ウイルス感染に伴う局所の免疫変調によって起こったWolf ʼs isotopic responseであると考えた．以上のように，自験例および文献的考察から遠心性環状紅斑と帯状疱疹の強い因果関係が示唆された．
キーワード：遠心性環状紅斑，帯状疱疹，Wolf ʼs isotopic response．
J UOEH（産業医大誌）34（3）：225－ 229（2012）
228 S Ohmori et al
References
1 . Kim KJ, Chang SE, Choi JH, Sung KJ, Moon KC & Koh JK (2002): Clinicopathologic analysis of 66 cases of erythema annulare centrifugum. J Dermatol 29: 61-67
2 . Sugita K, Kabashima K & Tokura Y (2008): Erythema annulare centrifugum associated with herpes zoster. Eur J Dermatol 18: 205-206
3 . Lee HW, Lee DK, Rhee DY, Chang SE, Choi JH, Moon KC & Koh JK (2005): Erythema annulare cen-trifugum following herpes zoster infection: Wolf ʼs isotopic response? Br J Dermatol 153: 1241-1243
4 . Wolf R, Brenner S, Ruocco V & Filioli FG (1995): Isotopic response. Int J Dermatol 34: 341-348 5 . Zak-Prelich M, McKenzie RC, Sysa-Jedrzejowska A & Norval M (2003): Local immune responses
and systemic cytokine responses in zoster: relationship to the development of postherpetic neuralgia. Clin Exp Immunol 131: 318-323
eruptions later developed in the same region as the vesicular eruptions. We consider that this is Wolf ʼs isotopic response, which occurs at the site of an unrelated or healed cutaneous disease [4] and is caused by an alteration of the local immunity due to viral infection [3, 5]. Taken together, an etiologic relationship between EAC and herpes zoster is strongly suggested by the present case and by our review.
229EAC Associated with Herpes Zoster
帯状疱疹に関連した遠心性環状紅斑の1例
大森 俊1，杉田 和成1，杉田 篤子2，中村 元信1
1 産業医科大学 医学部 皮膚科学教室2 産業医科大学 医学部 精神医学教室
要 旨：遠心性環状紅斑は隆起性の紅斑や蕁麻疹様丘疹が遠心性に周囲へ拡大し，輪状ないし環状の形態を呈する．しばしば内臓悪性腫瘍に関連して発症することがあり，また真菌，細菌，ウイルス感染も遠心性環状紅斑の誘因になるとされている．症例は35歳の男性で，1週間前より体幹部（皮膚分節Th8-10）に疼痛を伴う水疱を自覚していた．それに付随して，体幹部には複数の環状紅斑も出現していた．前者の皮疹を帯状疱疹，後者を遠心性環状紅斑と診断した．環状紅斑の病変部よりDNAを抽出するも，水痘帯状疱疹ウイルスのDNAは検出されなかった．したがってこの環状紅斑は，ウイルス感染に伴う局所の免疫変調によって起こったWolf ʼs isotopic responseであると考えた．以上のように，自験例および文献的考察から遠心性環状紅斑と帯状疱疹の強い因果関係が示唆された．
キーワード：遠心性環状紅斑，帯状疱疹，Wolf ʼs isotopic response．
J UOEH（産業医大誌）34（3）：225－ 229（2012）
