Erythema gyratum repens-like psoriasis

A 28-year-old man was admitted to our department for investigation in 1992. He presented with a red, scaly, centrifugally spreading eruption, which ha d appeared in 1990, beginning on the neck and thorax, and later extending t o the trunk and limbs. The cutaneous lesions, located mainly on the trunk a nd proximal upper limbs, were arranged in rings, with a slightly raised pro minent scaling edge (Fig. 1a). The characteristic feature was the presence of rings or waves within already existing rings, whereas the central part w as flattened, with the texture of normal skin. The concentric figurate lesi ons resembled a wood grain pattern (Fig. 1b). The clinical picture was stri kingly similar to tinea imbricata; there was, however, no itching, and repe ated mycologic studies did not disclose Trichophyton concentricum. The histology was not characteristic. The epidermis, which was slightly ede matous, was covered with a heavy crust. In the dermis, a sparse inflammator y infiltrate, somewhat more pronounced in the subpapillary areas, was compo sed of lymphocytes with some eosinophils. Periodic acid-Schiff (PAS) and ot her stains for mycotic infection were negative. The general condition was not affected and laboratory studies did not show any abnormalities, except for low serum protein (5.1 g/L) and decreased gam ma globulins (10.5%). Cell-mediated immunity was preserved. Immunofluoresce nce studies (direct and indirect) were negative. In spite of repeatedly negative mycotic examinations and due to the strikin g similarity to tinea imbricata, we applied various antimycotic therapies ( terbinafine, itraconazole), with no effect. The figurate pattern, with norm al skin in between, altered from day to day, while new concentric rings app eared within the cleared skin. The migrating rate was about 2-3 cm per 2 we eks. The patient had undergone a thorough search for internal malignancy. D uring the follow-up period of 1992-98, cutaneous involvement slowly became almost generalized (1996), and the confluent lesions formed large plaques, but still with pronounced concentric rings. Transitional blood eosinophilia (27% in 1993 and 11% in 1996) regressed wit h no therapy. Since 1995, antibodies to HBs and HBc have been present with no clinical symptoms of liver disease. The blood proteins increased to 7.0 g/L, and gamma globulins to 17.2% (normal). The histology, studied repeated ly, started to display some signs of psoriasis from 1996 and, in 1998, was already consistent with the disease (Fig. 2). REPUVA (0.8 mg/kg acitretin a nd UVA 0.8 J/cm(2)) was applied for 2 weeks before the patient interrupted the therapy. In spite of this, there was further improvement and, in 1999, the patient was almost free of lesions with some abortive rings left. From time to time, single vesicles appeared within the elevated borders of the r ings. The histology of such vesicles was consistent with abortive pustular psoriasis (Fig. 3).