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Erythema annulare centrifugum
Clinical review Erythema annulare centrifugum Garrett S. Bressler, M.D., and Robert E. Jones, Jr., M.D. Birmingham, AL If one reviews the literature on the subject of erythema annulare centrifugum, it becomes quite obvious there is considerable confusion about the clinical presentation and histopathologic findings. This confusion is exemplified by the various quotes from dermatologic texts and scientific publications. Darier, who originally described the disease, described an annular, indurated, erythematous lesion without a scale that histologically was characterized by a superficial and deep lymphohistiocytic infiltrate and normal epidermis. Ackerman suggested that there are two types of gyrate erythema, a superficial type showing a scale, and the deep type as described by Darier, After reviewing the literature and studying patients with gyrate erythemas, it seems that there are two distinct types best termed the superficial and deep forms of gyrate erythema. Dermatologists use the term erythema annulare centrifugum to denote both of these forms. Perhaps that term should be discarded. (J AM ACAD DERMATOL 4:597-602, 1981.)
They appear in the fonn of a pink pimple, of 1-1.5 em. in diameter, flat, or sometimes at its birth, depressed at the center and edge. At the touch the finger feels a general induration or more often already an excrescence. Soon the edge extends eccentrically, in a ring of a vivid pink, 4-6 mm. in size, 2-3 mm. in height, giving to the touch the sensation of a hard string. At the same time the central area depresses itself to the level of the neighboring tegument and regains the normal aspect, except for a slight pigmented or purplish coloration ... .-Darier l
The histological examination of a portion of a ring, dissected out of his back on May 29, 1889, has shown: a normal and intact epidermis, a moderate edema of the papillary corps and of the corium, a slightly accentuated, diffused cellular infiltrate. In the entire thickness of the dermis one notices the presence of thick perivascular sleeves, whose elements are in immense majority lymphocytes and small conjunctive cells, with few polynuclears and very few mast cells, the plasmatic cells are absent.-Darier 1
Usually the external border is slightly scaly. Rarely is it steep, with a firm, rubber-like induration while the internal border presents a gentle slope. Typically the surface is devoid of scales, crusts or vesicles, and there are no local or general symptoms.-Domonkos 2 The lesion presents as a small, pink, infiltrated papule that extends slowly peripherally, forming arcuate lesions with a palpable peripheral scaling border with some central hyperpigmentation; vesiculation rarely occurs.-MoscheUd'
On histopathologic examination, a dense coat-sleeve perivascular disposition of lymphocytes and a few eosinophils in the upper and middle dermis are seen; some parakeratosis and spongiosis of the epidermis may be seen.Moschella3
From the Department of Dermatology, University of Alabama Medical Center.
Reprint requests to: Dr. Robert E. Jones. Jr., 1025 South 18th St., Birmingham, AL 352561205-933-8221.
0190-9622/81/050597+06$00.60/0 © 1981 Am Acad Dermatol
597
Journal of the
598
Bressler and Jones
Fig. 1. Deep gyrate erythema. A typical clinical lesion showing the serpiginous character with prominent slightly elevated outer margins and absence of a scale.
American Academy of Dermatology
Fig. 3. Superficial gyrate erythema. Clinical photograph of the lesion shown microscopically in Fig. 4. Note the characteristic circular erythematous patch with a scale on the inner margin and the biopsy site on the right side taken to demonstrate the inner scale.
In this disorder one observes annulare or serpiginous lesions with a red , raised , firm, walllike border that in the course of weeks extends peripherally. -s-Lever"
A cellular infiltrate showing a fairly sharply demarcated perivascular "coat-sleeve-like" arrangement is present in the middle and lower portions of the dermis . The infiltrate consists of mononuclear cells .-Lever 4
Erythema annulare centrifugum (EAC) is a dermal erythema characterized by enlarging polycyclic lesions and scaiing.-Demis 5
The chief pathologic characteristic is a focal infiltration of lymphocytes around blood vessels and dermal appendages . In addition, intercellular and intracellular edema with microscopic vesiculation of the epidermis may occur.-Demis 5
Gyrate erythemas are of two types: (I) superficial and (2) deep . . " Clinically, the lesions of the deep type are firmer than those of the superficial type, and they lack peripheral scales. Ackerman"
Superfi cial gyrate erythema: Moderately dense superficial perivascular infiltrate of lymphocytes and some histiocytes, and, rarely, eosinophil s; slight edema of the papillary dermis; focal spongiosis; focal parakeratosis occasionally. Deep gyrate erythema: Moderately dense lymphohistiocytic infiltrate around the blood vessels of the superficial and deep plexuses.-Ackerman 6
Volume 4 Number 5 May, 19&1
Erythema annulare centrifugum
599
,. -
Fig. 2. Deep gyrate erythema. A, A scanning power shows the typical superficial and deep perivascular lymphohistiocytic infiltrate with normal epidermis. B, Higher power shows the normal epidermis and the typical perivascular distribution of lymphocytes and histiocytes . C, Still higher power shows lymphocytes and histiocytes around capillaries. The figured lesions have edematous , sometimes vesicular borders . Scales are uncommon but when present may lag behind the advancing border and be present only on its inner side.Goltz and Burgdorf'
Biopsy of the active border reveals a subacute inflammatory process , with lymphocytes and occasionally eos inophils , about the blood vessels of the upper dermis. Perivascular cuffing may be so pronounced as to be considered by some as diagnostic for EAC. -r-Golt: and Burgdorf"
600
Bressler and Jones
As one reads the preceding quotations, from Darier! in 1916 to Goltz? in 1979, it is evident that there is considerable ambiguity regarding the precise nature of the clinical and histologic features of erythema annulare centrifugum. Since Darier's original description of erythema annulare centrifugum, a number of authors have reported various types of annular erythemas and included them as cases of erythema annu1are centrifugum, while other authors have created new names. Thus, a hodgepodge of confusing terminology has evolved which makes the understanding of these conditions very difficult for the dermatologist, pathologist, and especially the resident. We have attempted to present an accurate historical evolution of erythema annulare centrifugum with its related entities and hopefully support a unified concept of the gyrate erythemas. In 1891, Colcott Fox 8 described a persistent annular erythema which he termed erythema gyratum perstans . Wende," in 1908, under the title of "Erythema Figuration Perstans, " reported a case he felt to be unique among the annular erythemas. Wende stated: "This variety presents with persistent erythematous patches which assume annular, marginate and gyrate forms differing essentially from other varieties of erythemas. " Darier, in 1916, published the following account entitled "The Centrifugal Ring-Shaped Erythema' ': L, 26 years of age, painter, comes to see me on May 15, 1889, to find out whether or not he is affected by syphilis, so he was told by several physicians who he has consulted. I noticed that he has an eruption of circles and rings, abounding on the lumbar region, on the back of his thighs, scattered on the sides of his back . . .. At the touch the finger feels a general induration . . .. I have not ascertained at any time any indication of vesiculation or of peeling. . . Finally, itching was almost completely absent. Darier clearly stated that erythema annulare centrifugum was different from Fox's erythema gyration perstans in that Fox's patients manifested a generalized scaly eruption with remarkable itching. Darier also distinguished patients with erythema annu1are centrifugum from those of Wende's in that the latter exhibited marked scaling.
Journal of the American Academy of Dermatology
Between 1916 and 1932, a number of papers were written on the subject of persistent gyrate erythemas. Graham and Thorne 10 in 1930 considered their patients to be identical to those of Darler's and referred to them as "cases of erythema annulare centrifugum." Other authors reported similar clinical entities with names such as "erythema simplex gyratum" and "erythema microgyratum persistens. "11,12 In 1932, Butler!" reported a case of erythema annul are centrifugum and attempted to emphasize the unique nature of this entity. Butler stated: When a keen observer described a condition having distinct peculiarities that appear to him to be sufficiently pathognomonic to accord the disease a special title and recording, there usually follows a large number of articles by others who feel that they recognize in more or less ordinary dermatoses the peculiarities of this newly described condition .... In conclusion, one may state that erythema annulare centrifugum as described by Darier, is an exceedingly rare dermatosis and that on grounds of the gyrate arrangement observers who are not meticulously careful are prone to include too many conditions under this title. From 1932 to the present, dermatologists have attempted to classify and define erythema annulare centrifugum and other persistent erythemas in a variety of ways; however, considerable confusion still exists. In 1954, Ellis and Friedman'! reviewed erythema annulare centrifugum and presented a general concept: In the cases described by Darier there was no vesiculation, scaling or lamination. Darier thus could not accept the cases of Wende and others, but the other features are so similar that they are all probably the same disease with slight clinical variations. Ellis and Friedman concluded that erythema annulare centrifugum is apparently a toxicoderrnatosis and the infiltrated forms have been reported as id reactions due to epidermatophytons, breast cancer, infections, and other disease. Even among modern textbooks erythema annulare centrifugum is characterized as scaly or nonscaly,
Volume 4 Number 5 May, 1981
Erythema annulare centrifugum
Fig. 4. Superficial gyrate erythema. A, Low power shows a superficial perivascular lymphohistiocytic infiltrate with slight spongiosis and microvesiculation. B, High power shows slight spongiosis. C, High power to show the lymphocytes and histiocytes around capillaries in the papillary dermis and a mound of parakeratosis overlying an area of mild intercellular edema.
601
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vesicular or nonvesicular, and pruritic or asymptomatic. 3.5,7 After a review of the literature, it is apparent that Darier's term •'erythema annul are centrifugum" has evolved into one which encompasses a number of clinical and histologic entities. Among these entities there appear to be two distinct groups which we feel are identical to the superficial and deep gyrate erythemas described by Ackerman. 6 Darier and others described the deep type!' that were recurrent, red, annular lesions with firm, cordlike borders (Fig. 1). The lesions were devoid of vesicles and scales, and there was very little or no pruritus. Histologically, one sees a superficial and deep lymphohistiocytic infiltrate, occasionally edema of the papillary dermis, and no parakeratosis or spongiosis (Fig. 2). The second group (superficial gyrate erythema)" includes those patients characterized clinically by persistent annular forms with nonindurated borders (Fig. 3). The surface of the lesion is scaly, rarely vesicular, and the patient may complain of pruritus. The histologic features are a superficial perivascular 1ymphohistiocytic infiltrate, edema of the papillary dermis, slight spongiosis and parakeratosis at the border of the lesion (Fig. 4). The etiology of these erythemas is obscure, although a host of etiologic factors have been implicated, including drugs, dermatophytes, and other agents. Erythema gyratum repens is the name given to the deep form when it is found in association with internal malignancy. Erythema chronicum migrans is used when the deep form occurs following an insect bite. Histologically, the differential diagnosis of the superficial type includes pityriasis rosea, and the deep type, lymphocytic infiltrate of Jessner and polymorphous light eruption. CONCLUSIONS
1. Erythema annul are centrifugum as first described by Darier consists clinically of recurrent, arcuate lesions with no scales or vesicles and a firm, erythematous border. Histologically, a su-
perficial and deep perivascular 1ymphohistiocytic infiltrate, often with slight edema of the papillary dermis and no spongiosis, characterizes the lesion. 2. A second group of chronic erythemas is characterized clinically by persistent, annular lesions with a surface that is scaly at the edges. The typical histologic appearance consists of a superficial perivascular 1ymphohistiocytic infiltrate with spongiosis and mounds of parakeratosis at the borders of the lesion. 3. We advocate not using the term erythema annulare centrifugum since it has lost its initial meaning and includes two apparently different diseases. Instead, we prefer Ackerman's terms superficial gyrate erythema and deep gyrate erythema, referring to distinct clinicopathologic entities. REFERENCES 1. Darier J: De 1'erytheme annulaire centrifuge. Ann Derrnatol Syphilol 6:57-76, 1916. 2. Domonkos AL: Disease of the skin. Philadelphia, 197I, W. B. Saunders Co., pp. 148-149. 3. Moschella SF: Dermatology. Philadelphia, 1974, W. B. Saunders Co., vol. I, pp. 391-392. 4. Lever WF: Histopathology of the skin, ed. 5. Philadelphia. 1975, J. B. Lippincott Co., pp. 133-134. 5. Demis OJ: Clinical dermatology. New York, 1977, Harper & Row, Publishers, Inc., vol. 2, unit 7-5, pp. 1-3. 6. Ackerman AB: Histologic diagnosis of inflammatory skin diseases. Philadelphia, 1978, Lea & Febiger, pp. 174-175,231-233,283-284. 7. Goltz RW, Burgdorf W, in Fitzpatrick TB, et ai, editors: Dermatology in general medicine. New York, 1979, McGraw-Hill Book Co., pp. 669-671. 8. Fox TC; Erytema gyratum perstans, in International atlas of rare skin diseases. London, 1891, J. & A. Churchill, Ltd., pp. 1-3. 9. Wende FW: Erythema figuration perstans. JAMA 51: 1936-1939, 1908. 10. Graham TN, Thorne B: Erytheme annulaire centrifuge: Report of 6 cases. Arch Dermatol Syph 22:776-789, 1930. 11. Jadassohn J: Erythema simplex gyratum, in Handbuch der Haul. 1928, vol. 2, pp. 656-657. 12. Strempe RL: Erytheme mikrogyratum persistens. Dermatol Ztschr 36:63-65, 1922. 13. Butler J: Erythema annulare centrifugum, Arch Derrnarol Syph 25:111-119, 1932. 14. Ellis FA, Friedman AA: Erythema annulare centrifugum (Darier 's): Clinical and histologic study. Arch Dermatol 70:496-507, 1954.
They appear in the fonn of a pink pimple, of 1-1.5 em. in diameter, flat, or sometimes at its birth, depressed at the center and edge. At the touch the finger feels a general induration or more often already an excrescence. Soon the edge extends eccentrically, in a ring of a vivid pink, 4-6 mm. in size, 2-3 mm. in height, giving to the touch the sensation of a hard string. At the same time the central area depresses itself to the level of the neighboring tegument and regains the normal aspect, except for a slight pigmented or purplish coloration ... .-Darier l
The histological examination of a portion of a ring, dissected out of his back on May 29, 1889, has shown: a normal and intact epidermis, a moderate edema of the papillary corps and of the corium, a slightly accentuated, diffused cellular infiltrate. In the entire thickness of the dermis one notices the presence of thick perivascular sleeves, whose elements are in immense majority lymphocytes and small conjunctive cells, with few polynuclears and very few mast cells, the plasmatic cells are absent.-Darier 1
Usually the external border is slightly scaly. Rarely is it steep, with a firm, rubber-like induration while the internal border presents a gentle slope. Typically the surface is devoid of scales, crusts or vesicles, and there are no local or general symptoms.-Domonkos 2 The lesion presents as a small, pink, infiltrated papule that extends slowly peripherally, forming arcuate lesions with a palpable peripheral scaling border with some central hyperpigmentation; vesiculation rarely occurs.-MoscheUd'
On histopathologic examination, a dense coat-sleeve perivascular disposition of lymphocytes and a few eosinophils in the upper and middle dermis are seen; some parakeratosis and spongiosis of the epidermis may be seen.Moschella3
From the Department of Dermatology, University of Alabama Medical Center.
Reprint requests to: Dr. Robert E. Jones. Jr., 1025 South 18th St., Birmingham, AL 352561205-933-8221.
0190-9622/81/050597+06$00.60/0 © 1981 Am Acad Dermatol
597
Journal of the
598
Bressler and Jones
Fig. 1. Deep gyrate erythema. A typical clinical lesion showing the serpiginous character with prominent slightly elevated outer margins and absence of a scale.
American Academy of Dermatology
Fig. 3. Superficial gyrate erythema. Clinical photograph of the lesion shown microscopically in Fig. 4. Note the characteristic circular erythematous patch with a scale on the inner margin and the biopsy site on the right side taken to demonstrate the inner scale.
In this disorder one observes annulare or serpiginous lesions with a red , raised , firm, walllike border that in the course of weeks extends peripherally. -s-Lever"
A cellular infiltrate showing a fairly sharply demarcated perivascular "coat-sleeve-like" arrangement is present in the middle and lower portions of the dermis . The infiltrate consists of mononuclear cells .-Lever 4
Erythema annulare centrifugum (EAC) is a dermal erythema characterized by enlarging polycyclic lesions and scaiing.-Demis 5
The chief pathologic characteristic is a focal infiltration of lymphocytes around blood vessels and dermal appendages . In addition, intercellular and intracellular edema with microscopic vesiculation of the epidermis may occur.-Demis 5
Gyrate erythemas are of two types: (I) superficial and (2) deep . . " Clinically, the lesions of the deep type are firmer than those of the superficial type, and they lack peripheral scales. Ackerman"
Superfi cial gyrate erythema: Moderately dense superficial perivascular infiltrate of lymphocytes and some histiocytes, and, rarely, eosinophil s; slight edema of the papillary dermis; focal spongiosis; focal parakeratosis occasionally. Deep gyrate erythema: Moderately dense lymphohistiocytic infiltrate around the blood vessels of the superficial and deep plexuses.-Ackerman 6
Volume 4 Number 5 May, 19&1
Erythema annulare centrifugum
599
,. -
Fig. 2. Deep gyrate erythema. A, A scanning power shows the typical superficial and deep perivascular lymphohistiocytic infiltrate with normal epidermis. B, Higher power shows the normal epidermis and the typical perivascular distribution of lymphocytes and histiocytes . C, Still higher power shows lymphocytes and histiocytes around capillaries. The figured lesions have edematous , sometimes vesicular borders . Scales are uncommon but when present may lag behind the advancing border and be present only on its inner side.Goltz and Burgdorf'
Biopsy of the active border reveals a subacute inflammatory process , with lymphocytes and occasionally eos inophils , about the blood vessels of the upper dermis. Perivascular cuffing may be so pronounced as to be considered by some as diagnostic for EAC. -r-Golt: and Burgdorf"
600
Bressler and Jones
As one reads the preceding quotations, from Darier! in 1916 to Goltz? in 1979, it is evident that there is considerable ambiguity regarding the precise nature of the clinical and histologic features of erythema annulare centrifugum. Since Darier's original description of erythema annulare centrifugum, a number of authors have reported various types of annular erythemas and included them as cases of erythema annu1are centrifugum, while other authors have created new names. Thus, a hodgepodge of confusing terminology has evolved which makes the understanding of these conditions very difficult for the dermatologist, pathologist, and especially the resident. We have attempted to present an accurate historical evolution of erythema annulare centrifugum with its related entities and hopefully support a unified concept of the gyrate erythemas. In 1891, Colcott Fox 8 described a persistent annular erythema which he termed erythema gyratum perstans . Wende," in 1908, under the title of "Erythema Figuration Perstans, " reported a case he felt to be unique among the annular erythemas. Wende stated: "This variety presents with persistent erythematous patches which assume annular, marginate and gyrate forms differing essentially from other varieties of erythemas. " Darier, in 1916, published the following account entitled "The Centrifugal Ring-Shaped Erythema' ': L, 26 years of age, painter, comes to see me on May 15, 1889, to find out whether or not he is affected by syphilis, so he was told by several physicians who he has consulted. I noticed that he has an eruption of circles and rings, abounding on the lumbar region, on the back of his thighs, scattered on the sides of his back . . .. At the touch the finger feels a general induration . . .. I have not ascertained at any time any indication of vesiculation or of peeling. . . Finally, itching was almost completely absent. Darier clearly stated that erythema annulare centrifugum was different from Fox's erythema gyration perstans in that Fox's patients manifested a generalized scaly eruption with remarkable itching. Darier also distinguished patients with erythema annu1are centrifugum from those of Wende's in that the latter exhibited marked scaling.
Journal of the American Academy of Dermatology
Between 1916 and 1932, a number of papers were written on the subject of persistent gyrate erythemas. Graham and Thorne 10 in 1930 considered their patients to be identical to those of Darler's and referred to them as "cases of erythema annulare centrifugum." Other authors reported similar clinical entities with names such as "erythema simplex gyratum" and "erythema microgyratum persistens. "11,12 In 1932, Butler!" reported a case of erythema annul are centrifugum and attempted to emphasize the unique nature of this entity. Butler stated: When a keen observer described a condition having distinct peculiarities that appear to him to be sufficiently pathognomonic to accord the disease a special title and recording, there usually follows a large number of articles by others who feel that they recognize in more or less ordinary dermatoses the peculiarities of this newly described condition .... In conclusion, one may state that erythema annulare centrifugum as described by Darier, is an exceedingly rare dermatosis and that on grounds of the gyrate arrangement observers who are not meticulously careful are prone to include too many conditions under this title. From 1932 to the present, dermatologists have attempted to classify and define erythema annulare centrifugum and other persistent erythemas in a variety of ways; however, considerable confusion still exists. In 1954, Ellis and Friedman'! reviewed erythema annulare centrifugum and presented a general concept: In the cases described by Darier there was no vesiculation, scaling or lamination. Darier thus could not accept the cases of Wende and others, but the other features are so similar that they are all probably the same disease with slight clinical variations. Ellis and Friedman concluded that erythema annulare centrifugum is apparently a toxicoderrnatosis and the infiltrated forms have been reported as id reactions due to epidermatophytons, breast cancer, infections, and other disease. Even among modern textbooks erythema annulare centrifugum is characterized as scaly or nonscaly,
Volume 4 Number 5 May, 1981
Erythema annulare centrifugum
Fig. 4. Superficial gyrate erythema. A, Low power shows a superficial perivascular lymphohistiocytic infiltrate with slight spongiosis and microvesiculation. B, High power shows slight spongiosis. C, High power to show the lymphocytes and histiocytes around capillaries in the papillary dermis and a mound of parakeratosis overlying an area of mild intercellular edema.
601
602
Journal of the American Academy of Dermatology
Bressler and Jones
vesicular or nonvesicular, and pruritic or asymptomatic. 3.5,7 After a review of the literature, it is apparent that Darier's term •'erythema annul are centrifugum" has evolved into one which encompasses a number of clinical and histologic entities. Among these entities there appear to be two distinct groups which we feel are identical to the superficial and deep gyrate erythemas described by Ackerman. 6 Darier and others described the deep type!' that were recurrent, red, annular lesions with firm, cordlike borders (Fig. 1). The lesions were devoid of vesicles and scales, and there was very little or no pruritus. Histologically, one sees a superficial and deep lymphohistiocytic infiltrate, occasionally edema of the papillary dermis, and no parakeratosis or spongiosis (Fig. 2). The second group (superficial gyrate erythema)" includes those patients characterized clinically by persistent annular forms with nonindurated borders (Fig. 3). The surface of the lesion is scaly, rarely vesicular, and the patient may complain of pruritus. The histologic features are a superficial perivascular 1ymphohistiocytic infiltrate, edema of the papillary dermis, slight spongiosis and parakeratosis at the border of the lesion (Fig. 4). The etiology of these erythemas is obscure, although a host of etiologic factors have been implicated, including drugs, dermatophytes, and other agents. Erythema gyratum repens is the name given to the deep form when it is found in association with internal malignancy. Erythema chronicum migrans is used when the deep form occurs following an insect bite. Histologically, the differential diagnosis of the superficial type includes pityriasis rosea, and the deep type, lymphocytic infiltrate of Jessner and polymorphous light eruption. CONCLUSIONS
1. Erythema annul are centrifugum as first described by Darier consists clinically of recurrent, arcuate lesions with no scales or vesicles and a firm, erythematous border. Histologically, a su-
perficial and deep perivascular 1ymphohistiocytic infiltrate, often with slight edema of the papillary dermis and no spongiosis, characterizes the lesion. 2. A second group of chronic erythemas is characterized clinically by persistent, annular lesions with a surface that is scaly at the edges. The typical histologic appearance consists of a superficial perivascular 1ymphohistiocytic infiltrate with spongiosis and mounds of parakeratosis at the borders of the lesion. 3. We advocate not using the term erythema annulare centrifugum since it has lost its initial meaning and includes two apparently different diseases. Instead, we prefer Ackerman's terms superficial gyrate erythema and deep gyrate erythema, referring to distinct clinicopathologic entities. REFERENCES 1. Darier J: De 1'erytheme annulaire centrifuge. Ann Derrnatol Syphilol 6:57-76, 1916. 2. Domonkos AL: Disease of the skin. Philadelphia, 197I, W. B. Saunders Co., pp. 148-149. 3. Moschella SF: Dermatology. Philadelphia, 1974, W. B. Saunders Co., vol. I, pp. 391-392. 4. Lever WF: Histopathology of the skin, ed. 5. Philadelphia. 1975, J. B. Lippincott Co., pp. 133-134. 5. Demis OJ: Clinical dermatology. New York, 1977, Harper & Row, Publishers, Inc., vol. 2, unit 7-5, pp. 1-3. 6. Ackerman AB: Histologic diagnosis of inflammatory skin diseases. Philadelphia, 1978, Lea & Febiger, pp. 174-175,231-233,283-284. 7. Goltz RW, Burgdorf W, in Fitzpatrick TB, et ai, editors: Dermatology in general medicine. New York, 1979, McGraw-Hill Book Co., pp. 669-671. 8. Fox TC; Erytema gyratum perstans, in International atlas of rare skin diseases. London, 1891, J. & A. Churchill, Ltd., pp. 1-3. 9. Wende FW: Erythema figuration perstans. JAMA 51: 1936-1939, 1908. 10. Graham TN, Thorne B: Erytheme annulaire centrifuge: Report of 6 cases. Arch Dermatol Syph 22:776-789, 1930. 11. Jadassohn J: Erythema simplex gyratum, in Handbuch der Haul. 1928, vol. 2, pp. 656-657. 12. Strempe RL: Erytheme mikrogyratum persistens. Dermatol Ztschr 36:63-65, 1922. 13. Butler J: Erythema annulare centrifugum, Arch Derrnarol Syph 25:111-119, 1932. 14. Ellis FA, Friedman AA: Erythema annulare centrifugum (Darier 's): Clinical and histologic study. Arch Dermatol 70:496-507, 1954.