- Email: [email protected]
Erythema gyratum repens without underlying disease
Journal of the American Academy of Dermatology
132 Correspondence lesions," and a third patient who had typical granuloma annularelesions at presentation. Oneofthese patients was believed to have a cancer or lymphoma before biopsy. In each of these cases histologic examination confirmed granuloma annulare.
Susan B. Mallory, MD Dermatology Division St. Louis Children's Hospital 400 S. Kingshighway Blvd. St. Louis, MO 63110
Erythema gyratum repens without underlying disease To the Editor: We enjoyed the recent report by Drs. Garrett and Roenigk of their patient with erythema gyratum repens (EGR) without underlying disease (J AM ACAD DERMATOL 1992;26:121-2). Several aspects of the paper incline us to comment. EGR continues to be one of the most specific cutaneous eruptions signifying an underlying malignancy, usually of the lung or breast. The reporting of a healthy patient with this distinctive eruption tends to engender skepticism regarding the diagnosis. No mention was made regarding the substance of the eruption or its symptoms. EGR may be palpable and classically has associated scale trailing the leading edge of the eruption. l In addition, the majority of patients with this eruption are afflicted with itching, a point not addressed in the article. Garrett and Roenigk noted that the rash experienced by their patient was "migrating." One of the characteristic aspects of EGR is its rapid (up to 1 em per day) movement. 2 A quantification of such progression would have supported their diagnosis, or, conversely, a very slow progression would leave the diagnosis open to question. The authors follow in the footsteps of others in citing Shelley and Hurley's case3 of a young woman with migratory erythema, scaling, and breast hypertrophy unassociated with a malignancy. The eruption subsided with reduction mammoplasty. The authors believed their patient to have erythema annulare centrifugum (not EGR) and accordingly entitled their article. They discussed the classical eruption of EGR described by Gammel4 in 1953 but noted differences between his patient and theirs. In addition, in a subsequent paper 4 years later, Shelley 5 again cites his patient as having had erythema annulare centrifugum. Finally, Garrett and Roenigk cite four other cases in which patients with EGR had no underlying malignancy. To that list we would like to add four more. Breathnach et a1. 6 reported a patient with bullous pemphigoid who experienced an EGR-like eruption. A year later Ingber et aI.7 described a patient with the CREST syndrome who also experienced an eruption resembling EGR. Finally, Cheesbrough and Williamson 8 noted two men with
pityriasis rubra pilaris in whom EGR developed as their eruptions were resolving. It seems that the appearance of EGR is truly not a manifestation of an internal malignancy with as high a frequency as previously believed or we need to tighten the diagnostic criteria for EGR to exclude the EGR-like eruptions, which may fit better into one or another of the several other gyrate erythema categories.
Alan S. Boyd, MD, and Kenneth H. Neldner, MD Department ofDermatology Texas Tech University Health Sciences Center Lubbock, Texas
REFERENCES 1. Langlois JC, Shaw JM, Odland GF. Erythema gyratum repens unassociated with internal malignancy. J AM ACAD DERMATOL 1985;12:911-3. 2. Leavell UW, Winternitz WW, Black JH. Erythema gyratum repens and undifferentiated carcinoma. Arch Dermatol 1967;95:69-72. 3. Shelley WB, Hurley HJ. An unusual autoimmune syndrome; erythema annulare centrifugum, generalized pigmentation and breast hypertrophy. Arch Dermatol 1960; 81:889-97. 4. Gammel JA. Erythema gyratum repens. Arch Derm Syph 1953;66:494-505. 5. Shelley WB. Erythema annulare centrifugum. Arch DermatoI1964;90:54-8. 6. Breathnach SM, Wilkinson JD, Black MM. Erythema gyratum repens-like figurate eruption in bullous pemphigoid. Clin Exp Dermatol 1982;7:401-6. 7. Ingber A, Pullman H, Nowell C. CRSET syndrom: Assoziation mit erytheme figuratum. Z Hautlcr 1983;58:1298-306. 8. Cheesbrough MJ, Williamson DM. Erythema gyratum repens: A stage in the resolution ofpityriasis rubra pilaris'! Clin Exp DermatoI1985;10:466-71.
Substance P and rosacea To the Editor: We read with interest the report of Kiirk9iioglu et al. (J AM ACAD DERMATOL 1991;25: 725-6) that demonstrated increased substance P (SP)immunoreactive nerves around the papillary dermal blood vessels in erythematous papules of rosacea. Investigation of vasoactive inflammatory mediators is important in this disease because SP and similar neuropeptides have properties that could qualify them for a role in the pathogenesis of rosacea. Patients with carcinoid syndrome in whom rosacea has developed have been reported. l SP, which is found in tumor extracts and plasma of these patients, is believed to be one of the mediators of the profound facial flushing in patients with carcinoid. 2 We have studied serum SP levels in patients with rosacea; preliminary results have been published earlier. 3 All control subjects had normal SP levels, but 9 of 23 rosacea patients had elevated values, ranging from 100 pgjml (two patients) to 450 pgjml. Seven of these patients had erythematotelangiectatic disease.
132 Correspondence lesions," and a third patient who had typical granuloma annularelesions at presentation. Oneofthese patients was believed to have a cancer or lymphoma before biopsy. In each of these cases histologic examination confirmed granuloma annulare.
Susan B. Mallory, MD Dermatology Division St. Louis Children's Hospital 400 S. Kingshighway Blvd. St. Louis, MO 63110
Erythema gyratum repens without underlying disease To the Editor: We enjoyed the recent report by Drs. Garrett and Roenigk of their patient with erythema gyratum repens (EGR) without underlying disease (J AM ACAD DERMATOL 1992;26:121-2). Several aspects of the paper incline us to comment. EGR continues to be one of the most specific cutaneous eruptions signifying an underlying malignancy, usually of the lung or breast. The reporting of a healthy patient with this distinctive eruption tends to engender skepticism regarding the diagnosis. No mention was made regarding the substance of the eruption or its symptoms. EGR may be palpable and classically has associated scale trailing the leading edge of the eruption. l In addition, the majority of patients with this eruption are afflicted with itching, a point not addressed in the article. Garrett and Roenigk noted that the rash experienced by their patient was "migrating." One of the characteristic aspects of EGR is its rapid (up to 1 em per day) movement. 2 A quantification of such progression would have supported their diagnosis, or, conversely, a very slow progression would leave the diagnosis open to question. The authors follow in the footsteps of others in citing Shelley and Hurley's case3 of a young woman with migratory erythema, scaling, and breast hypertrophy unassociated with a malignancy. The eruption subsided with reduction mammoplasty. The authors believed their patient to have erythema annulare centrifugum (not EGR) and accordingly entitled their article. They discussed the classical eruption of EGR described by Gammel4 in 1953 but noted differences between his patient and theirs. In addition, in a subsequent paper 4 years later, Shelley 5 again cites his patient as having had erythema annulare centrifugum. Finally, Garrett and Roenigk cite four other cases in which patients with EGR had no underlying malignancy. To that list we would like to add four more. Breathnach et a1. 6 reported a patient with bullous pemphigoid who experienced an EGR-like eruption. A year later Ingber et aI.7 described a patient with the CREST syndrome who also experienced an eruption resembling EGR. Finally, Cheesbrough and Williamson 8 noted two men with
pityriasis rubra pilaris in whom EGR developed as their eruptions were resolving. It seems that the appearance of EGR is truly not a manifestation of an internal malignancy with as high a frequency as previously believed or we need to tighten the diagnostic criteria for EGR to exclude the EGR-like eruptions, which may fit better into one or another of the several other gyrate erythema categories.
Alan S. Boyd, MD, and Kenneth H. Neldner, MD Department ofDermatology Texas Tech University Health Sciences Center Lubbock, Texas
REFERENCES 1. Langlois JC, Shaw JM, Odland GF. Erythema gyratum repens unassociated with internal malignancy. J AM ACAD DERMATOL 1985;12:911-3. 2. Leavell UW, Winternitz WW, Black JH. Erythema gyratum repens and undifferentiated carcinoma. Arch Dermatol 1967;95:69-72. 3. Shelley WB, Hurley HJ. An unusual autoimmune syndrome; erythema annulare centrifugum, generalized pigmentation and breast hypertrophy. Arch Dermatol 1960; 81:889-97. 4. Gammel JA. Erythema gyratum repens. Arch Derm Syph 1953;66:494-505. 5. Shelley WB. Erythema annulare centrifugum. Arch DermatoI1964;90:54-8. 6. Breathnach SM, Wilkinson JD, Black MM. Erythema gyratum repens-like figurate eruption in bullous pemphigoid. Clin Exp Dermatol 1982;7:401-6. 7. Ingber A, Pullman H, Nowell C. CRSET syndrom: Assoziation mit erytheme figuratum. Z Hautlcr 1983;58:1298-306. 8. Cheesbrough MJ, Williamson DM. Erythema gyratum repens: A stage in the resolution ofpityriasis rubra pilaris'! Clin Exp DermatoI1985;10:466-71.
Substance P and rosacea To the Editor: We read with interest the report of Kiirk9iioglu et al. (J AM ACAD DERMATOL 1991;25: 725-6) that demonstrated increased substance P (SP)immunoreactive nerves around the papillary dermal blood vessels in erythematous papules of rosacea. Investigation of vasoactive inflammatory mediators is important in this disease because SP and similar neuropeptides have properties that could qualify them for a role in the pathogenesis of rosacea. Patients with carcinoid syndrome in whom rosacea has developed have been reported. l SP, which is found in tumor extracts and plasma of these patients, is believed to be one of the mediators of the profound facial flushing in patients with carcinoid. 2 We have studied serum SP levels in patients with rosacea; preliminary results have been published earlier. 3 All control subjects had normal SP levels, but 9 of 23 rosacea patients had elevated values, ranging from 100 pgjml (two patients) to 450 pgjml. Seven of these patients had erythematotelangiectatic disease.