All That Is Round Is Not Fungus: A Differential Diagnosis of Annular Lesions

• Published in: Primary care reports Vol. 24; no. 7
• Main Authors: Kellawan, Karl, Wyatt Andrasik
• Format: Journal Article
• Language: English
• Published: Atlanta Relias Learning 01.07.2018
• Subjects: Dermatitis; Dermatology; Differential diagnosis; Disease; Eczema; Fungal infections; Fungi; Lesions; Lupus; Medical diagnosis; Primary care; Pruritus; Psoriasis; Respiratory tract; Skin; Skin diseases; Tropical diseases
• ISSN: 1040-2497; 2168-765X

First- or second-generation antihistamines Lichen planus Small, violaceous, polygonal-shaped papules and plaques with a diffuse network of white streaking. The location is suggestive when plaques are confined to the extensor surfaces of limbs, umbilical region, and sacrum.33 Physically removing scale can produce pinpoint bleeding, referred to as the “Auspitz sign,” characteristic of psoriasis.32 Extracutaneous manifestations including nail changes and asymmetric, oligoarthritis of the hands and feet commonly are seen in conjunction with cutaneous findings.34 The chronic nature of the disease often leads to complex treatment regimens requiring combination therapy to achieve control. [...]referral to a dermatologist is appropriate. Patients often are Caucasian women aged 15 to 40 years.42 Nearly 70% will have anti-SSA/Ro autoantibodies and up to 50% will fulfill four or more of the American College of Rheumatology's criteria for systemic lupus erythematous.1,41,42 Because of the transient nature of the eruption, treatment is centered around sun protection.42 If medical therapy is preferred, topical corticosteroids or antimalarial agents, such as hydroxychloroquine, can be used.41 Sarcoidosis Sarcoidosis is an idiopathic systemic disease characterized by non-caseating granulomas in multiple organ systems — mainly the lungs, but also the skin, lymph nodes, eyes, and salivary glands.7,9 The disease is more common in women and typically begins between the ages of 20 and 40 years.9 Interestingly, in the United States, there is marked racial variation, with sarcoidosis affecting African Americans more often than Caucasians.9 Skin involvement is seen in up to one-third of those affected and may be the first and/or only clinical sign of disease.7,9 Lesion morphology varies, presenting as multiple round papules, patches, or plaques that favor the face, neck, and areas of prior injury such as tattoos and scars.7 Color ranges from red to purple to brown.7 Annular configurations may be present when multiple papules coalesce or when plaques clear centrally.7 Applying pressure to the firm lesions causes blanching, sometimes revealing a yellow-brown (apple-jelly) color.7 Lesions are almost always asymptomatic, although rarely may itch.9 Diagnosis may be straightforward in a patient with a known history of sarcoidosis; however, with no prior history, a biopsy of the lesion will reveal non- caseating epithelioid granulomas.7 In newly diagnosed cases, a chest X-ray is warranted and, if abnormal, patients should be referred for pulmonary evaluation.9 Treating the underlying systemic disease often clears cutaneous lesions.9 Limited cutaneous eruptions can be treated with intralesional triamcinolone.9 Systemic corticosteroids are effective but generally are reserved for active pulmonary, ocular, cardiac, and central nervous system involvement or when skin disease is widespread.9 Seborrheic Dermatitis Seborrheic dermatitis is a common, chronic dermatosis present in up to 5% of the population.32 The pathogenesis has been linked to the overproduction of sebum and Malassezia yeasts. [...]eruptions occur in regions in which sebaceous glands are most active, such as the scalp, face, eyebrows, ears, and presternal area (see Figure 10), as well as large body folds such as the axillae and groin.36 Lesions are more common in men and are characterized by gradual onset of sharply demarcated patches or thin plaques that vary in color from red to orange to yellow. EM is self-limiting and usually resolves within weeks without complications.14 For limited cutaneous disease, symptomatic treatment with oral antihistamines or low-potency topical corticosteroids is sufficient.43 In recurrent cases precipitated by herpes simplex virus eruptions, chronic suppressive antiviral therapy with valacyclovir is effective.14 When oral lesions are present, topical corticosteroid gels and “swish and spit” rinses containing a mixture of lidocaine, diphenhydramine, and kaolin are helpful.14 In severely ill patients, systemic corticosteroids should be considered.43 Hansen’s Disease Hansen’s disease, also known as leprosy, is a rare, chronic granulomatous disease caused by Mycobacterium leprae.44 Although mostly a disease of the developing world, cases in the United States occur in those who have resided in foreign countries or those living in southeastern states with exposure to armadillos, a natural host.1,45 In almost all new cases, a history of close contact with an untreated, infected individual is obtainable.45 Once a patient is infected, the disease has an insidious onset and an incubation period that ranges from three to 20 years.1 Hansen’s disease primarily presents in two forms, tuberculoid leprosy and lepromatous leprosy.45 In both forms, cooler areas of the body such as the skin, peripheral nerves, upper respiratory tract, and eyes are affected.1,45 Warmer areas such as the axilla, groin, and scalp usually are spared.