Dermatology Online Journal

Stress-induced erythema annulare centrifugum
Sherrif F Ibrahim MD PhD¹, Jennifer Pryor MD², Francisco A Tausk MD^1,3
Dermatology Online Journal 15 (4): 15

1. Department of Dermatology
2. Department of Pathology
3. Department of Psychiatry
University of Rochester School of Medicine, Rochester, New York. sherrif_ibrahim@urmc.rochester.edu

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Abstract

Stress is known to play a role in the course of many skin diseases. We report here a case of erythema annulare centrifugum (EAC) that appeared to be associated with stressors in the patient's life. On multiple occasions, EAC appeared with these episodes and cleared upon their resolution without medical treatment. The patient was otherwise healthy and had no known previously reported associations for this condition.

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The relationship between stress and the skin has been a topic of discussion for many years. Although the precise mechanisms remain inconclusive, there is evidence supporting the influence of psychosocial factors on skin diseases such as psoriasis, atopic dermatitis, and cutaneous malignancy [1, 2]. We report here a case of recurrent erythema annulare centrifugum (EAC) in an otherwise healthy young male that appeared to be temporally associated with extreme stressors in the patient's life. A 36-year-old male presented with a pruritic rash of approximately one week duration. He stated that he had an identical eruption several years prior and questioned if there could possibly be a link between stress and his cutaneous findings. Interestingly, his first episode occurred while his wife was hospitalized and resolved a few days after her recovery. His suspicion associating stress and the skin stemmed from the fact that the current episode appeared days before his Ph.D. final defense. He stated that, aside from being nervous for the upcoming defense, he felt well, and denied antecedent infection or current use of any medications.

Figure 1	Figure 2

On exam, the patient had two large papular eruptions in annular configuration with central clearing, one involving the entire lower back, and the second, a smaller, similar plaque on the left abdomen (Fig. 1). The remainder of the exam was unremarkable, with no evidence suspicious for dermatophyte infection. Punch biopsy from the plaque on the patient's back demonstrated a normal epidermis with a superficial dermal perivascular lymphocytic infiltrate in a coat-sleeve distribution, consistent with EAC (Figure 2). Basic laboratory workup including complete blood count and comprehensive metabolic panel as well as chest X-ray were within normal limits. The patient successfully defended his Ph.D., and the eruption cleared within a few days without medical treatment.

The link between EAC and underlying physical stressors such as malignancy, infection, systemic illness, pregnancy, medications, surgery, and allergies has been well documented [3, 4]. In most cases, however, there is no associated cause. To our knowledge, there has not been a report of EAC occurring in association with emotional stress. While this would be a difficult etiology to prove, the temporal relationship to our patient's wife being ill and to his doctoral defense – followed by complete resolution upon withdrawal of the stressors – does support this notion. Moreover, the patient's own conception of the appearance of the rash at times of high stress is largely responsible for our hypothesis. Although, EAC has been reported to have a seasonal recurrence, there did not seem to be such a relationship for this patient [5]. Furthermore, the patient appeared to otherwise be in good health without evidence of other known triggers of EAC.

The complex relationship between physical and emotional stress, the immune system, and manifestations of these interactions is fascinating and for the most part, a mystery. It is certainly reasonable to assume that the body might respond to physical stress in mechanisms that overlap with those due to emotional stress, making the appearance of EAC during times of high emotional stress a plausible proposition.

References

1. Tausk FA, Nousari H. Stress and the skin. Arch Dermatol. 2001 Jan;137(1):78-82. [PubMed]

2. Parker J, Klein SL, McClintock MK, Morison WL, et al. Chronic stress accelerates ultraviolet-induced cutaneous carcinogenesis. J Am Acad Dermatol. 2004 Dec;51(6):919-22. [PubMed]

3. Willard RJ, Zell D. Erythema Annulare Centrifigum. Emedicine. April 11, 2006.

4. Thami GP, Sachdeva A, Kaur S, Mohan H, Kanwar AJ. Erythema annulare centrifugum following pancreatico-biliary surgery. J Dermatol. 2002 Jun;29(6):347-9. [PubMed]

5. García Muret MP, Pujol RM, Gimenez-Arnau AM, Barranco C. Annually recurring erythema annulare centrifugum: a distinct entity? J Am Acad Dermatol. 2006 Jun;54(6):1091-5. [PubMed]

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