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Indian J Dermatol. 2013 Mar-Apr; 58(2): 157. PMCID: PMC3657228

doi: 10.4103/0019-5154.108071

Annular Lesions in Dermatology

Naveen Kikkeri Narayanasetty, Varadraj V Pai, and Sharatchandra B Athanikar
From the Department of Dermatology, Sri Dharmasthala Manjunatheshwara College of Medical Sciences and Hospital (SDMCMS and
H), Sattur, Dharwad, India
Address for correspondence: Dr. Naveen Kikkeri Narayanasetty, Department of Dermatology, No 10, Skin OPD, Sri Dharmasthala
Manjunatheshwara College of Medical Sciences & Hospital (SDMCMS&H), Sattur, Dharwad, India. E-mail: [email protected]

Received 2012 Apr; Accepted 2012 Jul.

Copyright : Indian Journal of Dermatology

This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0
Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Annular lesions are extremely common and striking in appearance, but can also be misleading. The
term annular stems from the Latin word annulus, meaning ringed. Herein, we enumerate different
presentations of annular lesions.

Annular lesions are classified as Table 1.

Table 1
Causes for annular lesions

Tinea corporis is characterized by annular or polycyclic lesions with erythematous and vesicular or
scaly border with central clearing[1] Figure 1]. Tinea imbricata is an unusual form of tinea corporis
caused by Trichophyton concentricum, which is characterized by itchy, non-inflammatory, concentric
rings.[2] In bullous impetigo, occasionally the bullae spreads peripherally with central clearing,
producing annular lesions called Impetigo Circinata. Varnish like yellow crust gives clue to diagnosis.
[3] Secondary syphilis may be present as annular lesions. A thin white ring of scales on the surface of
the lesion (Biette's collarette) is a valuable sign.[4]

Figure 1
Tinea corporis showing peripheral spreading with central clearing

In leprosy, annular lesions usually represent borderline cases. There is loss of sensation over the lesion.
[5] Lupus vulgaris may assume annular shape with central thin superficial scar and apple jelly nodule
at the edge of the lesion[3] [Figure 2]. Cutaneous leishmaniasis presents with small furuncle at the site
of inoculation with gradual peripheral spreading and central crusting giving annular appearance.[6] In
secondary stage of Trypanosomiasis, transient erythematous or urticarial rashes, with circinate and

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annular pattern, will develop on the trunk.[7] Erythema multiforme has target lesions which has three
zones: a central area of dusky erythema or purpura, a middle paler zone of oedema, and an outer ring of
erythema with well-defined edge.[8]

Figure 2
Lupus vulgaris

Chronic plaque psoriasis (psoriasis vulgaris) plaque, sometimes extends peripherally, the central part
undergoes clearing, causing the formation of annular lesions called annular psoriasis, [Figure 3] which
has good prognosis.[9] Subacute annular pustular psoriasis is a generalized type of pustular psoriasis
characterized by multiple annular lesions with erythema, scaling, and pustules at the periphery.[10]
Annular lichen planus is violaceous in color with very narrow rim of activity and a depressed, slightly
atropic center found on penis.[11] Annular lichenoid dermatitis is a distinct entity in youth.[12,13]
Herald patch of pitryiasis rosea is an oval or round lesion with typical collarette of scale at the margin.
[14] Porokeratosis of Mibelli presents as a dry annular plaque surrounded by a raised, fine keratotic
wall with characteristic furrow in it.[15]

Figure 3
Annular psoriasis. Central cleared zone is often immune to
psoriasis

Bullous pemphigoid, in the early stage presents as urticarial lesions. The erythematous component may
become serpiginous, with peripheral blister.[16] Subcorneal pustular dermatoses (Sneddon-Wilkinson
disease) presents as oval, peasized flaccid pustules which rupture easily, and tend to coalesce, forming
annular or serpiginous patterns with a scaly edge. Characteristically, pus accumulates in the lower half
of a fully developed pustule, leaving clear fluid in the upper half. Linear immunoglobulin A (IgA)
dermatosis presents as lesions comprising urticated plaques and papules, and annular, polycyclic
lesions often with blistering around the edge, the string of pearls sign [Figure 4][17].

Figure 4
Linear IgA dermatosis showing string of pearls appearance

Granuloma annulare presents as closely set, skin-colored, firm, smooth asymptomatic papules arranged
in a ring-like fashion [Figure 5]. Lesions usually resolve on its own without leaving any telltale mark.
[18]

Figure 5
Granuloma annulare in a diabetic

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Subacute cutaneous lupus erythematosus (SCLE) [Figure 6] and Neonatal lupus erythematosus (NLE)
presents as annular polycyclic lesions. 95% cases of NLE and 70% cases of SCLE show positivity for
Anti-Ro/SSa auto antibodies.[19,20]

Figure 6
Sub acute lupus erythematosus

Petaloid form of seborrhoic dermatitis sometimes assume annular pattern consisting of multiple
circinate patches, with a fine branny scaling in their centers, and with dark-red papules with larger
greasy scales at their margins.[21] After an acute phase, nummmular or discoid eczema may progress
towards a less vesicular and more scaly stage, often with central clearing, and peripheral extension,
causing ring-shaped or annular lesions. Nummular patches may accompany the more typical dry,
erythematous scaling patches of atopic dermatitis. Meyerson described two patients with multiple
pruritic, papulosquamous lesions surrounding melanocytic naevi which resolved spontaneously and
termed it as Meyerson phenomenon or Halo eczema.[22]

Figurate erythemas are a group of dermatoses mostly developing in response to an underlying

condition. Erythema gyratum repens is characterized by multiple, annular, concentric, rapidly growing
erythematous plaques with a trailing scale resembling wood grain.[23] Erythema anulare centrifugum
(EAC) presents as multiple, annular, polycyclic, slowly growing erythematous plaques with a trailing
scale. It is usually pruritic and often spares palms and soles.[24] Erythema chronicum migrans is a skin
finding at early stages of borreliosis, and erythema marginatum is the rapidly disappearing
erythematous rash of acute rheumatic fever.[25] Annular erythema of infancy has clinical morphology
of EAC but occurs in infancy.[26] Erythema gyratum atrophicans transiens neonatale is now felt to be a
variant of NLE.[27] Autosomal dominant annular erythema is noted in a family and termed as familial
annular erythemas.[28] Neutrophilic and vasculitic annular eruptions includes acute hemorrhagic
oedema of infancy, erythema elevatum diutinum, urticarial vasculitis, Henoch-Schnlein purpura, and
some cases of leukocytoclastic vasculitis associated with myeloma, inflammatory bowel disease or
pregnancy.[29]

Basal cell carcinoma or rodent ulcer sometimes present as slowly expanding annular plaque with
translucent or pearly, raised periphery with central ulceration.[30] Mycosis fungoides in the initial
phase of T1/IA andT2/IB may present with annular plaques.[31]

Fixed drug eruptions presents as well-defined erythematous, violaceous or hyperpigmented macule

with erythematous ring around it [Figure 7]. It frequently involves oral mucosa, glans penis, hands, and
feet.[32]

Figure 7
Fixed drug eruption with erythematous ring. Sometimes
erythematous ring around old lesion is the only sign of recurrence

Purpura annularis telangiectoides or Majocchi's disease is a chronic pigmented purpuric dermatosis

characterized by punctiform red patechial telangiectatic patches, with centrifugal growth giving annular
or serpiginous appearance. Cayenne pepper spots are characteristic.[33] Annular purpura which may
occur when the skin is struck by table tennis ball (ping-pong patch) and in step aerobics.[34,35]
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Annular lesions may also rarely be found in lupus erythematosus (LE),[36] chronic variant of sweet
syndrome[37] and neutrophilic eccrine hidradinitis.[38]

Footnotes Go to:

Source of support: Nil

Conflict of Interest: Nil.

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