Erythema

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Erythema is redness of the skin caused by capillary congestion. It can be caused by infection, massage, electrical treatments, acne medication, allergies, exercise or solar radiation (sunburn), and waxing and plucking of the hairs any of which can cause the capillaries to dilate, resulting in redness. Erythema is a common side effect of radiotherapy treatment due to patient exposure to ionizing radiation.

Causes

It can be caused by infection, massage, electrical treatment, acne medication, allergies, exercise, solar radiation (sunburn), cutaneous radiation syndrome, niacin administration, vitamin A toxicity, or waxing and tweezing of the hairs—any of which can cause the capillaries to dilate, resulting in redness. Erythema is a common side effect of radiotherapy treatment due to patient exposure to ionizing radiation. Circumoral erythema has been described as a typical sign of acute oleander poisoning by ingestion.

Common Causes

Causes by Organ System

Cardiovascular	Kawasaki disease, Lomotil, Necrotising microvasculitis, Phlebitis
Chemical/Poisoning	1-Amino-2-propanol, 1-Pentanethiol, 1,2-Dibromoethane, 2-Amino-2-methylpropanol, 2,4,6-Trinitrotoluene, 3-Aminopyridine, 4-Aminopyridine, Abalone poisoning, Acetic acid, Acrolein, Acute pesticide poisoning, Adverse reaction to chemical, Alclometasone, Alcohol flush reaction, Alcohol tolerance, Alcoholism, Allyl Glycidyl Ether, Allylamines, Aluminum Phosphide, Aminopterin, Ammonium bituminosulfonate, Ammonium nitrate ingestion, Ammonium Nitrate, Ammonium Sulfamate, Amylcinnamic alcohol, Anisole, Anisyl alcohol, Asparagus Fern poisoning, Australian Umbrella Tree poisoning, Benaldehyde, Benomyl, Benyl alcohol, Benyl salicylate, Benzanthrone, Biphenyl, Bleeding heart (plant) poisoning, Boxwood poisoning, Bromates, Bromides, Butyl Alcohol, Candelabra cactus poisoning, Caper spruge poisoning, Carbon Tetrachloride, Caterpillar complication poisoning, Celgene, Chemical allergy, Chemical burn, Chemical poisoning, Chlordecone, Chlormezanone, Chloromethane, Churee poisoning, Cinnamic alcohol, Cinnamic aldehyde, Clematis poisoning, Clobetasol propionate, Crown of Thorns poisoning, Cyclohexanol, Cyclohexanone, Cypress spurge poisoning, Devil’s trumpet poisoning, Eflornithine, Elephant’s-ear poisoning, Epidemic dropsy, Ethotoin, Eucalyptus poisoning, Eugenol, Euphorbium poisoning, False cactus poisoning, Fishtail palm poisoning, Flax poisoning, Flowering spurge poisoning, Garden chrysanthemum poisoning, Geraniol, Geranium poisoning, Ginger lily poisoning, Gold salts, Heliotrope poisoning, High Melting Explosive, Hops poisoning, Houseleek poisoning, Hydroid poisoning, Hydroxycitronellal,Hydroquinone, Hydroxocobalamin, Isoeugenol, Japanese Boxwood poisoning, Jimsonweed poisoning, Leatherwood poisoning, Lewisite, Lidocaine (cream), Maidenhair tree poisoning, Maprotiline, Merbromin, Mercury poisoning, Methamidophos, Methyl Isocyanate, Methyl Tert-Butyl Ether, Methylene Chloride, Milkbush poisoning, Morpholine, Musk ambrette, N-Butyl Chloride, N-Methyl-2-Pyrrolidone, Nitric Acid, Nitroethane, Nitrofen, Nitrogen Dioxide, Nitromethane, Oak moss absolute, Orf, Oyster plant poisoning, Paraphenylenediamine, Pazopanib, Pentaborane, Pentachlorophenol, Peplomycin, Pepper Spray, Perazine, Peruvian lily poisoning, Phenolphthalein, Phenylbutazone, Phthalthrin, Piggyback plant poisoning, Pineapple sap poisoning, Plant poisoning (Datura stramonium), Plant poisoning (Datura suaveolans), Plant poisoning (Euphorbiaceae), Plumbago poisoning, Poinsettia poisoning, Potassium iodide, Primidone, Primrose poisoning, Pyrethrin, Pyridine, Saddleback caterpillar poisoning, Sandalwood oil, Sassafras Oil (herbal agent) , Sea onion poisoning, Sea wasp poisoning (Chironex fleckeri), Sea wasp poisoning (Chiropsalmus quadrigatus), Sea wasp poisoning, Selenium Dioxide, Senecio poisoning, Snake plant poisoning, Streptozocin, Tavaborole
Dental	No underlying causes
Dermatologic	Acne rosasea, Acne, Acrodermatitis chronica atrophicans, Angioedema, Aphthous ulcer, Bazin disease, Bedsores, Brazilian pemphigus foliaceus, Bronchial adenomata syndrome, Bullous palmoplantar erythrodysesthesia, Bullous Pemphigoid, Chloasma, Chrome contact allergy, Contact dermatitis, Dandruff, Dermatitis ab igne, Dermatitis, Dermatosis, Diaper rash, Duhring-Brocq disease, Ecthyma gangrenosum, Eczema, Eicosanoid, Enfuvirtide, Erysipelas, Erythema ab igne, Erythema annulare centrifugum, Erythema annulare, Erythema chronicum migrans, Erythema craquele, Erythema elevatum diutinum, Erythema induratum, Erythema infectiosum, Erythema marginatum, Erythema migrans, Erythema multiforme, Erythema neonatorum, Erythema nodosum, Erythema toxicum, Erythrokeratodermia variabilis et progressiva, Erythrokeratodermia variabilis, Erythromelalgia, Erythropoietic protoporphyria, Exfoliative erythroderma syndrome, Flushing, Granulosis rubra nasi, Harlequin-type ichthyosis, Histrelin, Ichthyosis, Impetigo herpetiformis, Impetigo, Incontinentia pigmenti, Intertrigo, Lamellar ichthyosis, Majocchi disease, Melasma, Millian erythema, Mucositis, Palmar erythema, Papular mucinosis, Peeling skin syndrome, Phytophotodermatitis, Pityriasis rubra pilaris, Pityriasis rubra, Prosector’s wart, Rhinophyma, Rosacea, Roseola infantum, Rowell syndrome, Seborrheic dermatitis, Seborrheic keratosis
Drug Side Effect	Acetazolamide, Acetylcysteine, Acyclovir, Allopurinol, Amifostine, Antibiotics, Anticonvulsants, Antihypertensive drug allergy, Aspirin, Axitinib, Barbiturates, Barium nitrate, Benoxaprofen, Benzodiazepines, Beta-lactam antibiotic, Betamethasone dipropionate, Betamethasone valerate, Bezafibrate, Bleomycin, Brentuximab vedotin, Cabozantinib, Calcium hypochlorite, Capecitabine, Carbamazepine, Cetrorelix, Chlorambucil, Chloroquine, Chlorpromazine, Chlorpropamide, Clindamycin, Clofazimine, Clofibrate, Cold panniculitis of Haxthausen, Coumarin, Cytosine arabinoside, caspofungin acetate, capsaicin, Dabrafenib, D-Aminolevulinic acid, Dapsone, Degarelix, Desmopressin, Dexamethasone, Diclofenac, Diltiazem, Diphenhydramine, Docetaxel, Doxorubicin, Drug Allergies, Erlotinib, Etravirine, Everolimus, Floxuridine, Flucytosine, Fluorouracil, Fosamprenavir, Gallium Citrate Ga 67, Herbal Agent, Hydraine, Hydralazine, Hydroxycarbamide, Hydrocortisone butyrate, Hyoscine, Ibritumomab tiuxetan, Ibuprofen, Idarubicin, Imiquimod, Ipilimumab, Isoniazid, Ixabepilone, Ketoprofen, Lamotrigine, Lapatinib ditosylate, Leflunomide, Luliconazole, Maté (herbal agent) adverse reaction, Meprobamate, Methscopolamine, Methyl Bromide, Methyldopa, Methyldopate, Methylphenidate, Metronidazole, Modafinil, Muromonab-CD3, Netupitant and palonosetron, Nevirapine, Oral contraceptives,Oxytetracycline, Paracetamol, Penicillamine, Penicillin, Peppermint Oil (herbal agent) , Phenobarbital, Phenytoin, Pipothiazine, Pomalidomide, Procainamide, permethrin, Procarbazine, prednisolone, Retinol, Quinine, Regorafenib, Sertaconazole, Sinecatechins, Sezary syndrome, Spinosad, Tazarotene, Tretinoin, Tolbutamide
Ear Nose Throat	No underlying causes
Endocrine	Glucagonoma Syndrome, Glucagonoma, Hyperoestrogenic states, Hyperthyroidism, Hypothyroidism
Environmental	Chilblains, Environmental factors, Heat rash, Heatstroke, Photosensitivity, Radiation burn
Gastroenterologic	Alcoholic Hepatitis, Cirrhosis, Colitis, Hepatic failure, Hepatitis B, Hepatitis C, Liver cirrhosis, Obstructive biliary disease, Palmar erythema
Genetic	Bloom syndrome, C1 esterase inhibitor deficiency, CHILD syndrome, Chondrodystrophia calcificans congenita, Chondrodystrophia punctata, Chromosome 9q deletion syndrome, Chronic recurrent multifocal osteomyelitis, Complement 5 deficiency, Conradi-Hunermann Syndrome, Davis syndrome, Familial cold urticaria, Giroux-Barbeau syndrome, Gitelman syndrome, Gottron syndrome, Hereditary C2 deficiency, Hereditary C4 deficiency, Hyper-IgE syndrome, Immunodeficiency with short limb dwarfism, Majeed syndrome, Microphthalmia-dermal aplasia-sclerocornea syndrome, Nephroblastomatosis, fetal ascites, macrosomia and Wilms tumor, Nephroblastomatosis, Nonbullous congenital ichthyosiform erythroderma, Omenn syndrome, Oudsthoorn disease, Recurrent hereditary polyserositis, Roberts syndrome, Sjogren-Larsson syndrome
Hematologic	No underlying causes
Iatrogenic	Bacillus Calmette–Guérin vaccine, Radiotherapy
Infectious Disease	Arcanobacterium haemolyticum, Athlete’s foot, Atypical measles syndrome, Bannwarrth syndrome, Blastomyces dermatitidis, Blastomycosis, Borrelia burgdorferi, Boutonneuse fever, Candida paronychia, Candidiasis, Cat scratch disease, Cellulitis, Chancroid, Chickenpox, Chikungunya, Chlamydia infection, Chlamydia psittaci, Chlamydia trachomatis, Coccidioides immitis, Coccidioidomycosis, Coxsackie, Cutaneous larva migrans, Cutaneous leishmaniasis, Dengue, Dermatophytids, Disseminated gonococcal infection, Edwardsiella tarda infection, Ehrlichiosis, Epstein Barr virus, Erythrovirus, Escherichia coli O157:H7, Fifth disease, Gnathostomiasis, Granuloma inguinale, Hand foot syndrome, Haverhill fever, Herpes simplex, Hibernian fever, Histoplasmosis, Human immunodeficiency virus, Infection, Infectious mononucleosis, Latent tuberculosis, Leishmaniasis, Lenalidomide, Leprosy, Leptospirosis, Levomepromazine, Loiasis, Lyme disease, Lymphogranuloma venereum, Measles, Mycobacterium leprae, Mycobacterium marinum, Mycobacterium tuberculosis, Mycoplasma pneumoniae, Mycoplasma, Neisseria meningitidis, Onchocerciasis, Orthopoxvirus, Parvovirus B19, Perinatal infection, Protothecosis, Psittacosis, Rat-bite fever, Relapsing fever, Rheumatic fever, Rickettsia conorii, Rickettsia orientalis, Rickettsia prowazekii, Rickettsia tsutsugamushi, Rickettsia typhi, Rickettsialpox, Rocky Mountain spotted fever, Rubella, Rubeola, Salmonella typhi, Sarcoptes scabiei, Scabies, Scarlet fever, Shingles
Musculoskeletal/Orthopedic	Myositis, Necrotising fascitis
Neurologic	Autonomic dysreflexia, Burning Feet Syndrome, Glioblastoma multiforme, Morton’s neuroma, Peripheral neuropathy
Nutritional/Metabolic	Pellagra
Obstetric/Gynecologic	Pruritic Urticarial Papules and Plaques of Pregnancy
Oncologic	Cutaneous T-cell lymphoma, Hypertrophic pulmonary osteoarthropthy, Lymphomatoid granulomatosis, Non-Hodgkin lymphoma, Paraneoplastic syndrome, Sezary syndrome
Ophthalmologic	No underlying causes
Overdose/Toxicity	No underlying causes
Psychiatric	No underlying causes
Pulmonary	No underlying causes
Renal/Electrolyte	Gitelman syndrome
Rheumatology/Immunology/Allergy	Allergic contact dermatitis, Allergies, Autoimmune disorders, Behcet’s Disease, Blau syndrome, Chronic necrotizing vasculitis, Crohn disease, Dermatomyositis, Discoid lupus erythematosus, Ethylenediamine dihydrochloride mix allergy, Graft versus host disease, Hypersensitivity, IgE mediated gastrointestinal food allergy, Inflammatory bowel disease, Insect allergy, Interleukin-2, Isothiazolinone allergy, Lupus erythematosus, Mercaptobenzothiazole allergy, Mixed Connective Tissue Disorder, Morphine allergy, Neonatal lupus syndrome, Non-Food Allergy, Novacaine drug allergy, P-Phenylenediamine allergy, Penicillin allergy, Polychondritis, Psoriasis, Pyoderma gangrenosum, Reiter’s syndrome, Rheumatoid arthritis, Scleredema adultorum, Scleroderma, Senear-Usher syndrome, Skin allergy
Sexual	No underlying causes
Trauma	No underlying causes
Urologic	No underlying causes
Miscellaneous	Brachioradial pruritus, Burns, Cyanea sting, Excess friction and sweating, Injury, Insect bite, Mosquito, Necrolytic migratory erythema, Palmar plantar erythrodysesthesia, Panniculitis, Reflex sympathetic osteodystrophy, Sarcoidosis

Causes in Alphabetical Order

Associated conditions

In about 30-50% of cases, the cause of Erythema is unknown.

Differentiating Erythema from Other Diseases

Different rash-like conditions can be confused with erythema and are thus included in its differential diagnosis. The various conditions that should be differentiated from erythema include:^[1]^[2]^[3]^[4]^[5]^[6]^[7]

Disease	Features
Impetigo	It commonly presents with pimple-like lesions surrounded by erythematous skin. Lesions are pustules, filled with pus, which then break down over 4-6 days and form a thick crust. It’s often associated with insect bites, cuts, and other forms of trauma to the skin.
Insect bites	The insect injects formic acid, which can cause an immediate skin reaction often resulting in a rash and swelling in the injured area, often with formation of vesicles.
Kawasaki disease	Commonly presents with high and persistent fever, red mucous membranes in mouth, “strawberry tongue“, swollen lymph nodes and skin rash in early disease, with peeling off of the skin of the hands, feet and genital area.
Measles	Commonly presents with high fever, coryza and conjunctivitis, with observation of oral mucosal lesions (Koplik’s spots), followed by widespread skin rash.
Monkeypox	The presentation is similar to smallpox, although it is often a milder form, with fever, headache, myalgia, back pain, swollen lymph nodes, a general feeling of discomfort, and exhaustion. Within 1 to 3 days (sometimes longer) after the appearance of fever, the patient develops a papular rash, often first on the face. The lesions usually develop through several stages before crusting and falling off.
Rubella	Commonly presents with a facial rash which then spreads to the trunk and limbs, fading after 3 days, low grade fever, swollen glands, joint pains, headache and conjunctivitis. The rash disappears after a few days with no staining or peeling of the skin. Forchheimer’s sign occurs in 20% of cases, and is characterized by small, red papules on the area of the soft palate.
Atypical measles	The symptoms commonly begin about 7-14 days after infection and present as fever, cough, coryza and conjunctivitis. Observation of Koplik’s spots is also a characteristic finding in measles.
Coxsackievirus	The most commonly caused disease is the Coxsackie A disease, presenting as hand, foot and mouth disease. It may be asymptomatic or cause mild symptoms, or it may produce fever and painful blisters in the mouth (herpangina), on the palms and fingers of the hand, or on the soles of the feet. There can also be blisters in the throat or above the tonsils. Adults can also be affected. The rash, which can appear several days after high temperature and painful sore throat, can be itchy and painful, especially on the hands/fingers and bottom of feet.
Acne	It is typical of teenagers, usually appears on the face and upper neck, but the chest, back and shoulders may have acne as well. The upper arms can also have acne, but lesions found there are often keratosis pilaris, not acne. The typical acne lesions are comedones and inflammatory papules, pustules, and nodules. Some of the large nodules were previously called “cysts“
Syphilis	It commonly presents with gneralized systemic symptoms such as malaise, fatigue, headache and fever. Skin eruptions may be subtle and asymptomatic It is classically described as: Non-pruritic bilateral symmetrical mucocutaneous rash Non-tender regional lymphadenopathy Condylomata lata and Patchy alopecia.
Molluscum contagiosum	The lesions are commonly flesh-colored, dome-shaped, and pearly in appearance. They are often 1-5 millimeters in diameter, with a dimpled center. Generally not painful, but they may itch or become irritated. Picking or scratching the lesions may lead to further infection or scarring. In about 10% of the cases, eczema develops around the lesions. They may occasionally be complicated by secondary bacterial infections.
Mononucleosis	Common symptoms include low-grade fever without chills, sore throat, white patches on tonsils and back of the throat, muscle weakness and sometime extreme fatigue, tender lymphadenopathy, petechial hemorrhage and skin rash.
Toxic erythema	It is a common rash in infants, with clustered and vesicular appearance.
Rat-bite fever	It commonly presents with fever, chills, open sore at the site of the bite and rash, which may show red or purple plaques.
Parvovirus B19	The rash of fifth disease is typically described as “slapped cheeks,” with erythema across the cheeks and sparing the nasolabial folds, forehead, and mouth.
Cytomegalovirus	The common symptoms include sore throat, swollen lymph nodes, fever, headache, fatigue, weakness, muscle pain and loss of appetite.
Scarlet fever	It commonly includes fever, punctate red macules on the hard and soft palate and uvula (Forchheimer’s spots), bright red tongue with a “strawberry” appearance, sore throat and headache and lymphadenopathy.
Rocky Mountain spotted fever	The symptoms may include maculopapular rash, petechial rash, abdominal pain and joint pain.
Stevens-Johnson syndrome	The symptoms may include fever, sore throat and fatigue. Commonly presents ulcers and other lesions in the mucous membranes, almost always in the mouth and lips but also in the genital and anal regions. Those in the mouth are usually extremely painful and reduce the patient’s ability to eat or drink. Conjunctivitis of the eyes occurs in about 30% of children. A rash of round lesions about an inch across, may arise on the face, trunk, arms and legs, and soles of the feet, but usually not on the scalp.
Varicella-zoster virus	It commonly starts as a painful rash on one side of the face or body. The rash forms blisters that typically scab over in 7-10 days and clears up within 2-4 weeks.
Chickenpox	It commonly starts with conjunctival and catarrhal symptoms and then characteristic spots appearing in two or three waves, mainly on the body and head, rather than the hands, becoming itchy raw pox (small open sores which heal mostly without scarring). Touching the fluid from a chickenpox blister can also spread the disease.
Meningococcemia	It commonly presents with rash, petechiae, headache, confusion, and stiff neck, high fever, mental status changes, nausea and vomiting.
Rickettsial pox	The first symptom is commonly a bump formed by a mite-bite, eventually resulting in a black, crusty scab. Many of the symptoms are flu-like including fever, chills, weakness and muscle pain but the most distinctive symptom is the rash that breaks out, spanning the person’s entire body.
Meningitis	It commonly presents with headache, nuchal rigidity, fever, petechiae and altered mental status.

Pathological Findings

Image courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology

External links

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↑ Hartman-Adams H, Banvard C, Juckett G (2014). “Impetigo: diagnosis and treatment”. Am Fam Physician. 90 (4): 229–35. PMID 25250996.
↑ Mehta N, Chen KK, Kroumpouzos G (2016). “Skin disease in pregnancy: The approach of the obstetric medicine physician”. Clin Dermatol. 34 (3): 320–6. doi:10.1016/j.clindermatol.2016.02.003. PMID 27265069.
↑ Moore, Zack S; Seward, Jane F; Lane, J Michael (2006). “Smallpox”. The Lancet. 367 (9508): 425–435. doi:10.1016/S0140-6736(06)68143-9. ISSN 0140-6736.
↑ Ibrahim F, Khan T, Pujalte GG (2015). “Bacterial Skin Infections”. Prim Care. 42 (4): 485–99. doi:10.1016/j.pop.2015.08.001. PMID 26612370.
↑ Ramoni S, Boneschi V, Cusini M (2016). “Syphilis as “the great imitator”: a case of impetiginoid syphiloderm”. Int J Dermatol. 55 (3): e162–3. doi:10.1111/ijd.13072. PMID 26566601.
↑ Kimura U, Yokoyama K, Hiruma M, Kano R, Takamori K, Suga Y (2015). “Tinea faciei caused by Trichophyton mentagrophytes (molecular type Arthroderma benhamiae ) mimics impetigo : a case report and literature review of cases in Japan”. Med Mycol J. 56 (1): E1–5. doi:10.3314/mmj.56.E1. PMID 25855021.
↑ CEDEF (2012). “[Item 87–Mucocutaneous bacterial infections]”. Ann Dermatol Venereol. 139 (11 Suppl): A32–9. doi:10.1016/j.annder.2012.01.002. PMID 23176858.

[pmid25250996-1] Hartman-Adams H, Banvard C, Juckett G (2014). “Impetigo: diagnosis and treatment”. Am Fam Physician. 90 (4): 229–35. PMID 25250996.

[pmid27265069-2] Mehta N, Chen KK, Kroumpouzos G (2016). “Skin disease in pregnancy: The approach of the obstetric medicine physician”. Clin Dermatol. 34 (3): 320–6. doi:10.1016/j.clindermatol.2016.02.003. PMID 27265069.

[MooreSeward2006-3] Moore, Zack S; Seward, Jane F; Lane, J Michael (2006). “Smallpox”. The Lancet. 367 (9508): 425–435. doi:10.1016/S0140-6736(06)68143-9. ISSN 0140-6736.

[pmid26612370-4] Ibrahim F, Khan T, Pujalte GG (2015). “Bacterial Skin Infections”. Prim Care. 42 (4): 485–99. doi:10.1016/j.pop.2015.08.001. PMID 26612370.

[pmid26566601-5] Ramoni S, Boneschi V, Cusini M (2016). “Syphilis as “the great imitator”: a case of impetiginoid syphiloderm”. Int J Dermatol. 55 (3): e162–3. doi:10.1111/ijd.13072. PMID 26566601.

[pmid25855021-6] Kimura U, Yokoyama K, Hiruma M, Kano R, Takamori K, Suga Y (2015). “Tinea faciei caused by Trichophyton mentagrophytes (molecular type Arthroderma benhamiae ) mimics impetigo : a case report and literature review of cases in Japan”. Med Mycol J. 56 (1): E1–5. doi:10.3314/mmj.56.E1. PMID 25855021.

[pmid23176858-7] CEDEF (2012). “[Item 87–Mucocutaneous bacterial infections]”. Ann Dermatol Venereol. 139 (11 Suppl): A32–9. doi:10.1016/j.annder.2012.01.002. PMID 23176858.

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