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Year : 1995  |  Volume : 61  |  Issue : 4  |  Page : 220-221

Herpes associated erythema multiforme annularis concentricum

Correspondence Address:
C M Kuldeep

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Source of Support: None, Conflict of Interest: None

PMID: 20952961

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A young man had large, concentric plaques over the back and extensors of forearms for eight weeks. Past history suggested recurrent herpes labialis. Serum anti HSV-1 IgG titre was raised to 32 micrograms/l and histopathology of an active lesion suggested erythema multiforme. Symptomatic treatment and oral zinc therapy subsided EM lesions but concentric depigmentation developed after healing

Keywords: Herpes simplex, Erythema multiforme

How to cite this article:
Kuldeep C M, Saraswat J, Sharma H, Mat. Herpes associated erythema multiforme annularis concentricum. Indian J Dermatol Venereol Leprol 1995;61:220-1

How to cite this URL:
Kuldeep C M, Saraswat J, Sharma H, Mat. Herpes associated erythema multiforme annularis concentricum. Indian J Dermatol Venereol Leprol [serial online] 1995 [cited 2019 Nov 18];61:220-1. Available from: http://www.ijdvl.com/text.asp?1995/61/4/220/4214

  Introduction Top

Herpes simplex virus (HSV) infection is a common cause of recurrent erythema multiforme (EM).[1] Genetic factors, stress and radiation may be associated with herpes associated erythema multiforme (HAEM).[2] EM usually presents as crops of erythematous papules evolving into "target" or vesiculobullous lesions over acral sites, trunk and mucous membranes. Occasionally bullae, papules and toxic epidermal necrolysis like lesions may be encountered. Spontaneous healing is usual which is often followed by hyperpigmentation or rarely depigmentation.[3] We report a case of HAEM with atypically big plaques showing numerous concentric rings, photosensitivity and post inflammatory depigmentation.

  Case Report Top

A 21-year-old man presented with the history of recurrent, itchy, annular eruptions with blistering over forearms and back, for past 8 weeks. Each episode was preceded by body ache and vesicular eruptions over both lips, suggesting herpes labialis.

Cutaneous examination revealed multiple erythematous plaques of more than 5 cm size, showing numerous concentric rings over the posterior aspect of forearms and back. Peripheral vesiculation was evident in the lesions over sun exposed areas. The healed lesions showed multiple, depigmented, concentric rings [Figure - 1] besides guttate depigmentation over lips. General and systemic examination was normal. Routine investigations, skin scraping for KOH mount/fungal culture, VDRL test and ELISA test for HIV were negative. Serum anti-HSV-1 IgG titre was significantly raised (32 micrograms/l). Histopathology of an active skin lesion demonstrated hydropic degeneration of basal cells, sub-epidermal bullae and lympho-histiocytic infiltrate around dermal blood vessels. He received symptomatic treatment and oral zinc sulphate (220 mg/day) for 6 months which resulted in complete remission of EM without recurrence during the follow up period.

  Discussion Top

Though target or 'iris' lesions are the hallmark of EM,[1] big plaques of enormous size with numerous concentric rings, photosenstivity and post-inflammatory depigmentation seen in this patient of HAEM seem to be unusual. The pathogenesis of concentric annular lesions in recurrent HAEM is still uncertain. It may be because of genetic predisposition, intermittent activation of HSV infection by endogenous or exogenous factors leading to the deposition of immune complexes in dermal blood vessels.[4],[5] Thereafter histamine release and its degradation by N-methyl transferase within the vicinity of the characteristic cone-shaped cutaneous vasculature also contribute in the pathogenesis of EM lesions. The cause of depigmentation following EM is still unknown but it may be because of direct melanocyte toxic effect of histmaine or atomic oxygen derived from hydroxyl and superoxide ions generated within the inflammatory cells.[3],[6] Oral zinc may control the recurrence of EM and depigmentation through immunomodulation.[6] The term herpes associated erythema multiforme annularis concentricum (HAEMAC) can better explain aetiology and morhology of such lesions.

  References Top

1.Huff JC, Weston WL, Tonnesen MG. Erythema multiforme. A critical review of characterstics, diagnostic criteria and causes. J Am Acad Dermatol 1983;8:763-75.  Back to cited text no. 1  [PUBMED]  
2.Kampgen E, Burg G, Wank R. Association of herpes simplex virus induced erythema multiforme with HLA-DQ W3. Arch Dermatol 1988;124:1372-3.  Back to cited text no. 2  [PUBMED]  
3.Bedi TR. Depigmenting erythema multiforme-A clinical and histophatological study. Ind J Dermatol Venereol Leprol 1980;46:117-20.  Back to cited text no. 3    
4.Imamura S, Horo T, Yanase K, et al. Erythema multiforme: pathomechanism of papular erythema and target lesion. J Dermatol 1992;19:524-33.  Back to cited text no. 4    
5.Kazmierowski JA, Peizner DS, Wuepper KD. Herpes simplex antigen in immune complexes of patients with erythema multiforme. JAMA 1982;2547-50.  Back to cited text no. 5    
6.Mathur NK, Bumb RA, Agarwal US. Oral zinc in recurrent erythema multiforme with depigmentation. Ind J Dermatol Venereol Leprol 1984;50:10-2.  Back to cited text no. 6    


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