Erythema Annulare Centrifugum Associated with Autoimmune Catamenial Dermatitis
- 1. Dermatology Resident, Universidad Tecnológica Equinoccial, Quito, Ecuador
- 2. Medical Dermatologist , Carlos Andrade Marin Hospital, Quito, Ecuador
- 3. Medical Dermatologist, Hospital Enrique Garcés, Physician Independent Researcher, Quito, Ecuador
Summary
Erythema Annulare Centrifugum can be considered today as a marker of multiple diseases; there are some reports that mention the presence of this skin pathology as an expression of autoimmune dermatitis due to progesterone. A case of erythema Annulare Centrifugum with recurrent evolution and difficult control is presented in a female patient in whom, after hormonal treatment, had a favorable response.
Keywords
• Progesterone autoimmunity
• Progesterone
• Menstruation
• Menstrual cycle
• Skin disease
CITATION
Chamorro Y, Ortega M, Lema K, Basantes A, Felix C, et al. (2024) Erythema Annulare Centrifugum Associated with Autoimmune Catamenial Dermatitis. J Dermatolog Clin Res 12(2): 1165.
ABBREVIATIONS
ANA: Antinuclear Antibodies; CT: Computed Tomography
INTRODUCTION
Autoimmune catamenial dermatosis is a rare pathology linked to hormonal fluctuations within the cycle during a woman’s reproductive age. There are theories of its pathophysiology given either by activation of catamenial receptors and the innate immune system in an aberrant manner, the formation of antibodies by B lymphocytes and by the survival of autoreactive cells either to Progesterone or Estrogen, and even both [1-3].
CLINICAL CASE
We present a 50 year-old woman with history of erythematous gastropathy, mixed hemorrhoids, chronic maxillary sinusitis, turbinate hypertrophy and surgical history of myomectomy, appendectomy, with allergy to zinc oxide. She had presented, for 6 years, lesions confirmed histopathologically as erythema annulare centrifugum that was later accompanied by idiopathic thrombocytopenic purpura. For the past two years, she has had recurrent exacerbated outbreaks, accompanied by joint pain and general discomfort prior to her menstruation. She received treatment with systemic and topical corticosteroids, as well as antihistamines with partial improvement of symptoms (Figure 1).
Figure 1: Legend. Initial injuries of the patient.
The differential diagnoses included erythema annulare centrifugum, Lupus erythematosis, Urticaria vasculitis, Catamenial dermatitis and tinea incognita. Therefore, a new biopsy was performed, and azathioprine and corticosteroid were prescribed at immunosuppressive doses with good response. During weaning from the corticosteroid the condition reactivated, so the dose was increased but lesions persisted, which prompted treatment with thalidomide and progesterone. The patient improved as the outbreaks became isolated and less intense. Treatment for Helicobacter pylori was instituted which lead to lesion reactivation with a vascular component, and systemic corticosteroid were resumed.
At the following visit, treatment was indicated with medroxyprogesterone 150 mg IM every 3 months, prednisone 5 mg daily and thalidomide 50 mg daily for 2 months, azathioprine 50 mg daily for 2 months and topical betamethasone for 15 days on the body and tacrolimus 0.03% on the face. With the treatment lesions resolved leaving post-inflammatory patches on the arms and face and isolated hypochromic macules and patches with erythematous border infiltrated on both arms.
Dermatopathology (Figure 2) of the right leg revealed orthokeratotic epidermis with exocytosis of few neutrophils, the vessels of the superficial dermis, surrounded by mononuclear infiltrate and neutrophils, causes mild endothelial swelling and nuclear dust between the collagen fibers, with diagnosis of: hypersensitivity vasculitis.
Figure 2: Legend. Histopathological examination. Few neutrophils, the vessels of the superficial dermis, surrounded by mononuclear infiltrate and neutrophils Vasculitis associated with hypersensitivity.
Among the relevant results of complementary examinations, the transvaginal ultrasound reports: Uterine myomatosis, CT abdomen: cystic image of 17x14 cm at the level of the distal area of the pancreatic tail. Chest CT: Reactive axillary lymph nodes, ANA, AntiDna , C3, C4, Anti Ro/La: Negative, ANA: Negative.
DISCUSSION
In cases of cyclic, treatment-resistan erythema annulare centrifugum one must consider an associated disease. When these cyclic episodes are related to menstruation, it is important to consider the diagnosis of autoimmune dermatitis due to progesterone. There is no clear evidence of diagnostic criteria, however, with the clinical history we can determine that the skin condition begins before the menstrual phase, which, having previously ruled out our differential diagnoses, is considered a diagnosis of exclusion [4-11].
CONCLUSIONS
The clinical improvement of the lesions can be observed thanks to treatment (Figure 3).
Figure 3: Clinical improvement at last control ten after ten months of treatment
Treatment should focus on inhibiting ovulation either with oral contraceptives or in severe and refractory cases, bilateral oophorectomy could deem necessary [12,15].
