Erythema Marginatum

There are many types of erythema, including erythema nodosum, erythema multiforme and the topic of this article, erythema marginatum. We will explain how erythema marginatum becomes a factor in rheumatic fever, and provide additional information about this specific rash.

What is erythema marginatum?

If you have a medical background, you already know that “erythema” refers to red, and “marginatum” refers to margin. Basically speaking, erythema marginatum is a rash or skin redness where the margins are elevated and thus easily visible.

Erythema marginatum is just one kind of annular erythema. The center is clear and flat, while the edges are elevated and red. They can be found on the extremities as well as the trunk. In most typical cases, the face, the palms of your hands and the soles of your feet will be unaffected if you have this condition. It may often be ignored, since it isn’t itchy or painful.

Photographs: Erythema Marginatum

article-3-pic-1Erythema marginatum related to rheumatic fever

article-3-pic-2Erythema marginatum may come and go and can remain on the skin even for a period of months.

article-3-pic-3Erythema marginatum is a major criterion in the diagnosis of rheumatic fever but it is not always present.

Photo Source: American College of Rheumatology

Erythema Marginatum – Causes

This skin rash or redness may be caused by an underlying medical condition, or it can be idiopathic. Red areas are caused by blood vessel inflammation. This results from an accumulation of white blood cells, especially lymphocytes. Since inflammation is part of the condition, it shows up as a rash on the surface of your skin.

There are various causes for erythema marginatum, but the main cause is rheumatic fever. Streptococcal bacterial infection causes this autoimmune disease. Erythema marginatum is typically included in the major Jones’ criteria, which are definitive of a case of rheumatic fever.

article-3-pic-4Diagnosis of rheumatic fever – Jones’ Criteria

Photo Source:

The occurrence of this rash is triggered by heat, which logically would account for the reason it appears about two or three weeks after fever starts. It appears on the trunk first, and then will spread towards the extremities. It may cover the whole body, with the exception of the face, palms of the hands and soles of the feet.

There is not a definite period of time when the rash will continue. It may persist for weeks or months, or indeed, even years. It can come and go. It may fade away by itself and come back again, after a period of weeks or even months. The instances of rash are about 1/2 to 2 cm in diameter.

Other potential conditions that lead to erythema marginatum include:

  • Allergies (the most common culprits are tomatoes and bleu cheese)
  • Lyme disease
  • Drugs, including chloroquine, cimetidine and penicillin
  • Infection from Escherichia coli, Ascaris lumbricoides or Candida albicans
  • Malignancy, particularly lymphoma, squamous cell carcinoma, breast cancer and leukemia
  • Pregnancy

Types and Incidences

There are two types of erythema marginatum. They are erythema marginatum perstans and erythema marginatum rheumaticum.

Erythema marginatum rheumaticum is the type that we just discussed. This type is associated with rheumatic fever. It is an asymptomatic type that occurs in superficial trunk and extremity areas.

Erythema marginatum perstans, on the other hand, is found in the deep and superficial skin areas in differing body parts, except for palms of hands and soles of feet.

In some countries, including the UK, rheumatic fever is quite rare. British physicians who work in general practice may never see a case. In the developed countries of the world, erythema marginatum is not often seen, even though it still remains a criterion for diagnosing rheumatic fever. The occurrence of erythema marginatum is so uncommon that it is only now seen in about two to three percent of cases of rheumatic fever.

Erythema Marginatum – Histopathology

article-3-pic-5Erythema Marginatum – Histologic Features

Photo Source:

In the above image, you will note that neutrophilic infiltrates are predominant, with accompanying nuclear dust. The dermal papillae show neutrophils. There are many dyskeratotic keratinocytes without any fibrinoid degeneration of the blood vessel walls.

Superficially, there are perivascular infiltrates of white blood cells notes, particularly the neutrophils and lymphocytes. This presence causes blood vessel inflammation, which accounts for the redness of the skin.

Erythema Marginatum – Differential Diagnosis

Another Jones’ criteria, subcutaneous nodule, can be seen over the body’s bony prominences, not on the extremities or trunk. It occurs mainly in the latter stages of rheumatic fever. Erythema marginatum occurs along with carditis. It may even occur earlier than the polyarthritis.

Erythema marginatum sometimes resembles urticaria, without the itchiness. Urticaria includes dermal edema, which is not seen in erythema marginatum. Erythema marginatum has only neutrophils and lymphocytes, while urticaria has these infiltrates in addition to eosinophils.

Biopsy results of erythema marginatum are neither definitive nor specific to the condition, since it has histological features that are similar to those of Still’s disease and acute lupus erythematosus. If vascular damage is evident, then leukocystoclastic vasculitis can be ruled out. If it is suspected that the cause is of an infectious origin, cultures and strains should be considered.

Erythema Marginatum versus Erythema Migrans

Erythema migrans resembles erythema marginatum except for the center, which looks like a bull’s eye. Erythema marginatum often spreads throughout the whole body while erythema migrans merely expands on localized parts.

Erythema marginatum is found in patients who are suffering from rheumatic fever. Erythema migrans, on the other hand, is commonly seen with among patients who have Lyme disease.


article-3-pic-7Photos of erythema migrans


Erythema marginatum by itself does not pose serious complications to one’s health, even if it persists for months or years. However, the underlying diseases that cause the rash may be serious. Erythema marginatum is not in its own sense a disease. It does not have any complications.

Erythema Marginatum – Treatment

Erythema marginatum requires no specific treatment, since it will fade without intervention. Patients may not even feel any indications that they have a rash. They may not even notice it. There are not any prescriptions available for treatment of erythema marginatum.

The conditions causing this rash do need treatment. To completely get rid of the rash, it is necessary to determine the underlying cause. Once this is completely treated, the rash will go away, as well.


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