Annular Lesions in Dermatology

Annular Lesions in Dermatology
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3657228/?report=printable
Indian J Dermatol. 2013 Mar-Apr; 58(2): 157.
PMCID: PMC3657228
doi: 10.4103/0019-5154.108071

Naveen Kikkeri Narayanasetty, Varadraj V Pai, and Sharatchandra B Athanikar
From the Department of Dermatology, Sri Dharmasthala Manjunatheshwara College of Medical Sciences and Hospital (SDMCMS and H),
Sattur, Dharwad, India
Address for correspondence: Dr. Naveen Kikkeri Narayanasetty, Department of Dermatology, No 10, Skin OPD, Sri Dharmasthala
Manjunatheshwara College of Medical Sciences & Hospital (SDMCMS&H), Sattur, Dharwad, India. E-mail: naveenkn80@yahoo.com
Received 2012 Apr; Accepted 2012 Jul.
Copyright : Indian Journal of Dermatology
This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Annular lesions are extremely common and striking in appearance, but can also be misleading. The term
annular stems from the Latin word annulus, meaning ringed. Herein, we enumerate different
presentations of annular lesions.
Annular lesions are classified as Table 1.
Tinea corporis is characterized by annular or polycyclic lesions with erythematous and vesicular or scaly
border with central clearing[1] Figure 1]. Tinea imbricata is an unusual form of tinea corporis caused by
Trichophyton concentricum, which is characterized by itchy, non-inflammatory, concentric rings.[2] In
bullous impetigo, occasionally the bullae spreads peripherally with central clearing, producing annular
lesions called Impetigo Circinata. Varnish like yellow crust gives clue to diagnosis.[3] Secondary syphilis
may be present as annular lesions. A thin white ring of scales on the surface of the lesion (Biette's
collarette) is a valuable sign.[4]
In leprosy, annular lesions usually represent borderline cases. There is loss of sensation over the lesion.[5]
Lupus vulgaris may assume annular shape with central thin superficial scar and apple jelly nodule at the
edge of the lesion[3] [Figure 2]. Cutaneous leishmaniasis presents with small furuncle at the site of
inoculation with gradual peripheral spreading and central crusting giving annular appearance.[6] In
secondary stage of Trypanosomiasis, transient erythematous or urticarial rashes, with circinate and annular
pattern, will develop on the trunk.[7] Erythema multiforme has target lesions which has three zones: a
central area of dusky erythema or purpura, a middle paler zone of oedema, and an outer ring of erythema
with well-defined edge.[8]
Chronic plaque psoriasis (psoriasis vulgaris) plaque, sometimes extends peripherally, the central part
undergoes clearing, causing the formation of annular lesions called annular psoriasis, [Figure 3] which has
good prognosis.[9] Subacute annular pustular psoriasis is a generalized type of pustular psoriasis
characterized by multiple annular lesions with erythema, scaling, and pustules at the periphery.[10] Annular
lichen planus is violaceous in color with very narrow rim of activity and a depressed, slightly atropic center
found on penis.[11] Annular lichenoid dermatitis is a distinct entity in youth.[12,13] Herald patch of
pitryiasis rosea is an oval or round lesion with typical collarette of scale at the margin.[14] Porokeratosis of
Mibelli presents as a dry annular plaque surrounded by a raised, fine keratotic wall with characteristic
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furrow in it.[15]
Bullous pemphigoid, in the early stage presents as urticarial lesions. The erythematous component may
become serpiginous, with peripheral blister.[16] Subcorneal pustular dermatoses (Sneddon-Wilkinson
disease) presents as oval, peasized flaccid pustules which rupture easily, and tend to coalesce, forming
annular or serpiginous patterns with a scaly edge. Characteristically, pus accumulates in the lower half of a
fully developed pustule, leaving clear fluid in the upper half. Linear immunoglobulin A (IgA) dermatosis
presents as lesions comprising urticated plaques and papules, and annular, polycyclic lesions often with
blistering around the edge, the string of pearls sign [Figure 4][17].
Granuloma annulare presents as closely set, skin-colored, firm, smooth asymptomatic papules arranged in a
ring-like fashion [Figure 5]. Lesions usually resolve on its own without leaving any telltale mark.[18]
Subacute cutaneous lupus erythematosus (SCLE) [Figure 6] and Neonatal lupus erythematosus (NLE)
presents as annular polycyclic lesions. 95% cases of NLE and 70% cases of SCLE show positivity for
Anti-Ro/SSa auto antibodies.[19,20]
Petaloid form of seborrhoic dermatitis sometimes assume annular pattern consisting of multiple circinate
patches, with a fine branny scaling in their centers, and with dark-red papules with larger greasy scales at
their margins.[21] After an acute phase, nummmular or discoid eczema may progress towards a less
vesicular and more scaly stage, often with central clearing, and peripheral extension, causing ring-shaped or
annular lesions. Nummular patches may accompany the more typical dry, erythematous scaling patches of
atopic dermatitis. Meyerson described two patients with multiple pruritic, papulosquamous lesions
surrounding melanocytic naevi which resolved spontaneously and termed it as Meyerson phenomenon or
Halo eczema.[22]
Figurate erythemas are a group of dermatoses mostly developing in response to an underlying condition.
Erythema gyratum repens is characterized by multiple, annular, concentric, rapidly growing erythematous
plaques with a trailing scale resembling wood grain.[23] Erythema anulare centrifugum (EAC) presents as
multiple, annular, polycyclic, slowly growing erythematous plaques with a trailing scale. It is usually pruritic
and often spares palms and soles.[24] Erythema chronicum migrans is a skin finding at early stages of
borreliosis, and erythema marginatum is the rapidly disappearing erythematous rash of acute rheumatic
fever.[25] Annular erythema of infancy has clinical morphology of EAC but occurs in infancy.[26]
Erythema gyratum atrophicans transiens neonatale is now felt to be a variant of NLE.[27] Autosomal
dominant annular erythema is noted in a family and termed as familial annular erythemas.[28] Neutrophilic
and vasculitic annular eruptions includes acute hemorrhagic oedema of infancy, erythema elevatum
diutinum, urticarial vasculitis, Henoch-Schnlein purpura, and some cases of leukocytoclastic vasculitis
associated with myeloma, inflammatory bowel disease or pregnancy.[29]
Basal cell carcinoma or rodent ulcer sometimes present as slowly expanding annular plaque with
translucent or pearly, raised periphery with central ulceration.[30] Mycosis fungoides in the initial phase of
T1/IA andT2/IB may present with annular plaques.[31]
Fixed drug eruptions presents as well-defined erythematous, violaceous or hyperpigmented macule with
erythematous ring around it [Figure 7]. It frequently involves oral mucosa, glans penis, hands, and feet.[32]
Purpura annularis telangiectoides or Majocchi's disease is a chronic pigmented purpuric dermatosis
characterized by punctiform red patechial telangiectatic patches, with centrifugal growth giving annular or
serpiginous appearance. Cayenne pepper spots are characteristic.[33] Annular purpura which may occur
when the skin is struck by table tennis ball (ping-pong patch) and in step aerobics.[34,35]
Annular lesions may also rarely be found in lupus erythematosus (LE),[36] chronic variant of sweet
syndrome[37] and neutrophilic eccrine hidradinitis.[38]
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Footnotes
Source of support: Nil
Conflict of Interest: Nil.
References
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14. Parsons JM. Pityriasis rosea update: 1986. J Am Acad Dermatol. 1986;15:15967. [PubMed: 3528239]
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28. Beare JM, Froggatt P, Jones JH, Neill DW. Familial annular erythema. An apparently new dominant
mutation. Br J Dermatol. 1966;78:5968. [PubMed: 5908098]
29. Nousari HC, Kimyai-Asadi A, Stone JH. Annular leukocytoclastic vasculitis associated with monoclonal
gammopathy of unknown significance. J Am Acad Dermatol. 2000;43:9557. [PubMed: 11044832]
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33. Majocchi D. Purpura annularis telangiectoides.Telangiectasis follicuritis annulata Arch Dermatol
Syph. 11898;43:44768.
34. Scott MJ, Jr, Scott MJ., III Pingpong patches. Cutis. 1989;43:3635. [PubMed: 2731441]
35. Allan SJ, Humphreys F, Buxton PK. Annular purpura and step aerobics. Clin Exp Dermatol.
1994;19:418. [PubMed: 7955503]
36. Piqu E, Palacios S, Santana Z. Leukocytoclastic vasculitis presenting as an erythema gyratum
repenslike eruption on a patient with systemic lupus erythematosus. J Am Acad Dermatol.
2002;47:S2546. [PubMed: 12399742]
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1994;31:53556. [PubMed: 8089280]
38. Scong VY, Appell ML, Sanders DY, Omura EF. Annular plaques on the dorsa of the hands. Neutrophilic
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eccrine hidradenitis. Arch Dermatol. 1991;127:13989. 1400-2. [PubMed: 1892412]

Figures and Tables
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Table 1
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Causes for annular lesions
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Figure 1
Tinea corporis showing peripheral spreading with central clearing
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Figure 2
Lupus vulgaris
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Figure 3
Annular psoriasis. Central cleared zone is often immune to psoriasis
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Figure 4
Linear IgA dermatosis showing string of pearls appearance
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Figure 5
Granuloma annulare in a diabetic
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Figure 6
Sub acute lupus erythematosus
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Figure 7
Fixed drug eruption with erythematous ring. Sometimes erythematous ring around old lesion is the only sign of recurrence
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Annular Lesions in Dermatology

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Indian J Dermatol. 2013 Mar-Apr; 58(2): 157.