Erythema annulare in adults with acute rheumatism.

In the winter of 1959-1960 the number of patients with acute rheumatism who applied to our Centre for treatment was larger than in former years, and most cases presented with a forme fruste of the condition. The three cases reported differed from the others in that they presented with erythema annulare (EA). The chief outward sign of erythema annulare is a series of rings about 2 mm. wide, with a diameter of 1-3 cm., pale pink to bluish-red in colour. The rings may show a festoon-like confluence, and may usually be observed on the trunk, and less frequently on the extremities. The fact that they are not raised above the skin surface indicates that there is little exudation, and because itching and desquamation are absent they often pass unnoticed. Sometimes the rings become fully visible only when the skin is exposed to heat or cold. The erythema is susceptible to rapid changes in shape and colour and is also influenced by emotion (Wallgren, 1935). Erythema annulare was described for the first time by Barlow (1883), who noted it in children with acute rheumatism, but as early as 1826, Rayer had called attention to the association of acute rheumatism and skin affections (Perry, 1937). Lehndorff and Leiner (1922) and Lehndorff (1930) asserted that erythema annulare occurred only in acute rheumatism, and only when there also existed a rheumatic affection of the heart. In this way, the condition has acquired an unfavourable prognostic significance. It has been said never to occur in babies and only seldom in adults (Abt, 1935; Pelle and Massot, 1937; Ablard and Larcan, 1956a, b; Slater and Rosenbaum, 1959), but it has been observed in approximately 10 per cent. of children with acute rheumatism (Lehndorff and Leiner, 1930). Wallgren (1935), who analysed the incidence of erythema annulare in a group of 148 children with acute rheumatism (Table), concluded that erythema annulare occurred three to four times more often in cases with severe cardiac involvement.