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An epidemic of 44 cases of milker's nodules was recorded in the Tampere Central Hospital catchment area in Finland during the autumn of 1974. Exanthema or erythema multiforme-like secondary eruptions were seen in 10 cases. One female patient is reported in detail because of the simultaneous occurrence of erythema nodosum and erythema multiforme. The virological diagnosis was confirmed by electron microscopy.
The case of a child with Colcott-Fox type of centrifugal annular chronic erythema is reported. It is a sporadic, non-familial form, associated with a bullous eruption, and an atrophic conjonctivitis with trichiasis. A review is made of 11 previously published cases, allowing a synthesis of their essential features. The action played by the slow reactive substances (S. R. S. A.) in the extension of the erythematous margin is discussed. The clinical diagnosis of centrifugal annular erythema is exposed.
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1. Exposure of the skin of rats to u.v. light (greater than 295 nm) for 30 s or longer elicited a delayed erythema response, the rate of onset increasing with period of irradiation. The erythema was still present at 24 h and was replaced by scab formation in 48 hours. 2. Both topically applied steroidal and non-steroidal anti-inflammatory drugs reduced the erythema formation when administered immediately after u.v. exposure. Propyl gallate, an antioxidant with sun screening properties in man, also possessed topical anti-erythemic activity. 3. Both steroidal and non-steroidal anti-inflammatory drugs, systemically administered 1 h before u.v. exposure, reduced and erythema. However, the steroidal compounds were less effective than the non-steroids and reduced the intensity of erythema by less than 50%. Antagonists of 5-hydroxytryptamine (5-HT) reduced the erythema but several other drugs with different pharmacological activities were ineffective. 4. Neither topical nor systemic treatments of any of the drugs examined suppressed the scab formation at 48 hours. 5. These results and those using other selective blocking agents indicate that in the mediation of the erythema reaction prostaglandins may play a major role and 5-HT perhaps a minor one but that H1 histamine receptors and alpha- and beta-adrenoceptors have no significant role.
A considerable amount of evidence exists in support of the role of ultraviolet radiation as a major etiologic factor in human skin cancer, both melanoma and carcinoma types. On the basis of epidemiologic studies a phenotype has been described which helps to identify the persons who are more susceptible to skin cancer. In an attempt to further define this population, patients with cutaneous carcinoma and a normal control group were exposed to artificial ultraviolet light (UVL) and the erythema and tanning responses of each group were measured over a 21-day period. UVL-induced erythema was prolonged in a significantly higher percentage of patients with skin cancer than in control patients, lasting two to three weeks after single exposures to 6 and 8 times the patient's minimal erythema dose. The presence of prolonged erythema correlated with this history of previous skin cancer but did not correlate with other established risk factors for cutaneous carcinoma, i.e., fair skin, light hair and light eyes, easy sunburning and poor tanning, and Celtic ancestry. Prolonged erythema following UVL radiation may therefore represent an additional risk factor and help to identify the skin cancer-susceptible population.
An outbreak of erythema infectiosum (fifth disease) occurred in a North Carolina elementary school. Because rubella virus has been implicated as a possible cause of some cases of erythema infectiosum, we conducted an investigation to determine if the children were infected with rubella virus and to learn whether or not rubella virus vaccination prevents the disease. Throat swabs were obtained for viral isolation from 20 children with erythema infectiosum and from 25 healthy classmates; questionnaires were completed for 617 of the school's 817 students. One hundred fifty children (24%) reported having an acute exanthematous illness during the study period, and 45% of the ill children had one or more household contacts with a similar rash. No viruses were recovered from the children, and a history of rubella vaccination did not affect the risk of developing erythema infectiosum.
To document association between erythema nodosum and concomitant fungus infection, we studied seven white women seen during a six-year period in our office practice. Five patients are presented. Unilateral erythema nodosum occurred in three patients on the same side as unilateral tinea. Tests with potassium hydroxide (KOH), cultures of nodules on Sabouraud agar and dermatophyte test medium (DTM), skin biopsy, and clinical examination ruled out nodular granulomatous perifolliculitis of Wilson. Lesions simulating erythema nodosum were produced when Trichophyton antigen was injected subcutaneously in the lower legs. All nodose and fungal lesions cleared after griseofulvin therapy. Fungus infection of feet or nails should be considered a possible cause of erythema nodosum when no other cause is apparent.
We report the history of a patient, who had recurrent patches of erythema on the trunk and extremities for some years. The diagnosis of erythema elevatum diutinum or annulare centrifugum was discussed. The patient developed a monoclonal IgA lambda fraction and clinical signs of myeloma. Treatment with cyclophosphamide stopped the development of erythema and also caused the M-component to disappear. This improvement has persisted even without cytostatic treatment. Another patient with prostatic carcinoma and relapsing annular erythema was cured of his skin lesions, when his carcinoma was treated with estrogens. The literature is reviewed.
Delayed type skin reactions in guinea pigs have been assessed by measuring three parameters: increase in skin thickness, diameter of erythema and intensity of erythema. Some groups of animals were immunized with different protein antigens in Freund's complete adjuvant with or without cyclophosphamide (CY) pretreatment; others received a single high dose of antigen intravenously at the time of immunization. The results emphasize the importance of measuring all three parameters for several days after skin testing. The intensity or erythema was found to be an especially useful parameter for assessing CY-induced modification of delayed hypersensitivity (DH) reactions. The increase in skin thickness, which can be measured objectively, was also valuable as both immediate and DH reactions are characterized by induration. The diameter of erythema could only be measured accurately for a short time after skin testing. Furthermore, the effects of intravenous antigen and CY pretreatment were not reflected by that parameter.
Relationship between delayed-in-onset erythema and infiltrating leucocytes in the skin reaction site of Jones-Mote type hypersensitivity was observed in guinea-pigs. Guinea-pigs were immunized with formalin-fixed (F-SRBC) or native form (N-SRBC) of sheep red blood cells in incomplete Freund's adjuvant (IFA). Elicitation was carried out with intradermal injection of F-SRBC or N-SRBC in saline 1 or 3 weeks after immunization. One week after immunization with F-SRBC or N-SRBC in IFA, erythema accompanied by basophil infiltration was detected, but antibody production was negative. Erythema reached a peak at 24 h, but basophil infiltration reached a peak at 48 h or later. In the skin reaction site elicited with N-SRBC, high levels of basophil infiltration were detected persistently even after erythema had disappeared. Three weeks after immunization, low titres of PCA (passive cutaneous anaphylaxis) were detected in guinea-pigs immunized with F-SRBC in IFA. At that time erythematous skin reaction was detected, but the level of basophil infiltration was lower than that of 1 week after immunization. In guinea-pigs immunized with N-SRBC in IFA, skin reaction of the Arthus type accompanied by haemorrhage was observed at the site elicited with N-SRBC.
A 15-year old male patient with Down-Syndrome suffering from a unusual vesicular type of erythema annular centrifugum Darier and a concurrent intestinal infection with candida albicans is described. Histology, immunhistological assay, and clinical observation allowed to differentiate Erythema annulare centrifugum from erythema exsudativum multiforme as well as dermatitis herpetiformis. On the basis of immunological findings and the clinical course, a hypersensitivity to candida albicans like a so-called "id-reaction" is assumed to be the main etiological factor in this case.
Seventy patients with cutaneous erythema of the feet with or without necrosis were the subjects of this investigation. Sixty-five of them had open diabetes. The glucose tolerance of the remaining five patients was altered in a diabetic direction. Twenty-seven of the 70 patients had roentgenologically demonstrable destruction in the bones of the feet. These 70 patients were compared with 61 diabetic control patients of corresponding age and duration of diabetes but without these skin lesions of the feet. Only four of the 61 control patients had destruction in the bones of the feet and all these destructions were small. Precipitating factors were identified in general for the skin lesions, the most common being cardiac decompensation. A higher frequency of precipitating factors was seen in patients with skeletal destructions than in those without. The skeletal destructions and cutaneous necrosis are supposed to be equivalent lesions, localized to different tissues in the feet. When patients presenting skin lesions of the feet in the form of distal gangrene were compared with those who had cutaneous erythema and necrosis of the feet, but no distal gangrene, no differences were found with respect to age, duration of diabetes, occurrence of precipitating factors and the occurrence of skeletal destruction. Cutaneous erythema without necrosis is understood to be incipient diabetic gangrene.
Erythema nodosum recurred in a woman during each of her four pregnancies and every time she was started on oral contraceptives. The lesions always disappeared in the fifth month of gestation or when contraceptives were withdrawn. Erythema nodosum is mediated by immune mechanisms, and both pregnancy and oral contraceptive use can interfere with the immune system. The concentrations of oestrogen and progesterone or the ratio between them may be critical to the development of erythema nodosum. The observation that the lesions spontaneously resolved in the fifth month of pregnancy supports this hypothesis.
The histopathology of erythema nodosum is discussed with reference to the literature and of 19 cases of our clinic. There is a significant vascular involvement especially of the subcutaneous tissue. The veins and arteries are equally affected. The histological picture consists not only of an acute inflammatory process in the subcutaneous tissue, but also of inflammatory cells which area see to a lesser extent in the dermis. In many cases the typical small granulomatous foci of MIESCHER which are considered to be pathognomonic for erythema nodosum do not develop. In the cases which we examined we were not always able to tell from the histological picture how long the erythema nodosum had been present. Multinucleated giant cells which are often found in the septal connective tissue are seen even in relatively acute cases.
Three infant boys with a centrifugal annular erythema mainly consistent with erythema annulare centrifugum, developing a few weeks after birth, are described. The lesions disappeared before the age of 6 months, without atrophy, and during this period the infants were otherwise healthy. This group is considered to belong to one of three types of reactivity in infants associated with or expressed as a connective tissue disease, especially lupus erythematosus, in the mother and child or in either. In type 1, signs and symptoms of systemic lupus erythematosus are or will be present in the mother and the child displays discoid lupus erythematosus lesions at birth or soon after. In type 2, the mother has the same signs and symptoms as in type 1 but the child develops a centrifugal annular erythema 3-6 weeks after birth. In type 3, discoid lupus erythematosus is present at an early stage in the infant, while the mother is healthy. This type may represent an early onset of lupus erythematosus in the infants.