Pediatric Dermatology Vol. 32 No. 3 e130–e131, 2015
Gravitational Erythema Abstract: We report a case of gravitational erythema in a 13-year-old boy who presented with a blotchy erythematous rash affecting his arms when hanging down and legs and lower abdomen on standing. The cutaneous symptoms in the upper limbs would resolve rapidly on elevation of the arms, whereas the lower limb rash would disappear on lying flat. Although this is a benign condition, no effective treatment has previously been reported. Our patient was managed with compression stockings, which provided some symptomatic benefit.
Figure 1. Rash appears on the leg while standing.
A 13-year-old boy presented to the dermatology clinic with a 2- to 3-year history of a blotchy erythematous rash affecting his arms, legs, and lower abdomen. This had been managed as idiopathic urticaria, but he did not respond to antihistamines. The rash on the arms would occur only with the arms hanging down, with abrupt resolution on elevation, whereas the rash on the legs and abdomen occurred only on standing and disappeared on lying flat. There was associated cutaneous discomfort. There were no other aggravating or alleviating factors. On examination, when standing, erythematous macules appeared on the lower limbs (Fig. 1) and extended proximally on prolonged standing to involve the lower abdomen as well as the upper limbs when in a dependent position. He also had dermographism. The rash on the arms and legs was reproducible by inflating a sphygmomanometer cuff to 60 mmHg for 2 to 3 minutes with the limb in the horizontal position (Fig. 2). He was managed with a trial of level II compression stockings, which did not completely resolve his skin symptoms, although when last reviewed, some clinical improvement was observed, with the erythematous macules in the legs taking longer to appear after standing, thereby providing some benefit.
DOI: 10.1111/pde.12556
e130
Figure 2. Erythematous macular rash on the right arm reproduced in the horizontal position by inflating a sphygmanometer cuff to 60 mmHg for 2 minutes.
DISCUSSION Gravitational erythema is a benign condition, and if its features are recognized early, further investigation is not warranted. It is characterized by the appearance of an erythematous macular eruption affecting the upper limbs in a dependent position and the lower limbs and trunk on standing, which resolves with elimination of gravity (1,2). Berth-Jones and GrahamBrown (1), who observed the appearance of lower limb macular erythema on standing, first described it in 1988 in a 16-year-old girl. In 2003 Perrett et al (2) described the dependent occurrence of this rash in the
© 2015 Wiley Periodicals, Inc.
Brief Report e131
limbs and abdomen of a 27-year-old man that would resolve when he raised his arms or laid flat. Pereira et al (3) noted similar findings in the upper limbs, and Monteiro et al (4) described a 10-year history of this clinical entity in the limbs of a 29-year-old woman. In all cases, the rash could be clinically reproduced by increasing venous pressure using a sphygmomanometer. The physiology of this condition has therefore been postulated to be secondary to an abnormal vascular response to changes in venous pressure. This may be due to ineffective or a lack of normal vasoconstriction on lowering a limb or may be due to functional abnormalities in arteriovenous communication (1,2). Determining the precise occurrence and dependent nature of the rash was important to the diagnosis. Also, its macular appearance and lack of response to antihistamines further differentiated it from urticaria. Clinically it can be reproduced using a sphygmomanometer. No recognized effective treatment for this benign but psychologically frustrating condition has been reported. This is the first case in which compression stockings were used to improve the rash in the lower limbs. Although compression stockings did not
prevent the rash from occurring, they delayed the onset of the rash and therefore were of some benefit to the patient. REFERENCES 1. Berth-Jones J, Graham-Brown RAC. Gravitational erythema. Clin Exp Dermatol 1988;13:259. 2. Perret CM, Berth-Jones J, Dharma B. Gravitational erythema. Br J Dermatol 2003;148:1267. 3. Pereira T, Vieira MD, Fernandes JC et al. Gravitational erythema. Pediatr Dermatol 2007;24:316–333. 4. Monteiro M, Aguiar EA, Boleira Sieiro Guimaraes M et al. Gravitational erythema. J Am Acad Dermatol 2009;60:AB46. Seher Rahmatulla, M.B.B.S., B.Sc. Krisztina Scharrer, M.D. Julia Schofield, M.B.Ch.B. (Honours), M.R.C.G.P., F.R.C.P. Khalid Hussain, M.B.B.S. Neill Hepburn, B.Sc., M.B.Ch.B., M.D. Department of Dermatology, Lincoln County Hospital, Lincoln, Lincolnshire, UK Address correspondence to Seher Rahmatulla, M.B.B.S., B.Sc., Lincoln County Hospital, Lincoln, Lincolnshire, UK, or e-mail: [email protected].
This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material.
Gravitational Erythema Abstract: We report a case of gravitational erythema in a 13-year-old boy who presented with a blotchy erythematous rash affecting his arms when hanging down and legs and lower abdomen on standing. The cutaneous symptoms in the upper limbs would resolve rapidly on elevation of the arms, whereas the lower limb rash would disappear on lying flat. Although this is a benign condition, no effective treatment has previously been reported. Our patient was managed with compression stockings, which provided some symptomatic benefit.
Figure 1. Rash appears on the leg while standing.
A 13-year-old boy presented to the dermatology clinic with a 2- to 3-year history of a blotchy erythematous rash affecting his arms, legs, and lower abdomen. This had been managed as idiopathic urticaria, but he did not respond to antihistamines. The rash on the arms would occur only with the arms hanging down, with abrupt resolution on elevation, whereas the rash on the legs and abdomen occurred only on standing and disappeared on lying flat. There was associated cutaneous discomfort. There were no other aggravating or alleviating factors. On examination, when standing, erythematous macules appeared on the lower limbs (Fig. 1) and extended proximally on prolonged standing to involve the lower abdomen as well as the upper limbs when in a dependent position. He also had dermographism. The rash on the arms and legs was reproducible by inflating a sphygmomanometer cuff to 60 mmHg for 2 to 3 minutes with the limb in the horizontal position (Fig. 2). He was managed with a trial of level II compression stockings, which did not completely resolve his skin symptoms, although when last reviewed, some clinical improvement was observed, with the erythematous macules in the legs taking longer to appear after standing, thereby providing some benefit.
DOI: 10.1111/pde.12556
e130
Figure 2. Erythematous macular rash on the right arm reproduced in the horizontal position by inflating a sphygmanometer cuff to 60 mmHg for 2 minutes.
DISCUSSION Gravitational erythema is a benign condition, and if its features are recognized early, further investigation is not warranted. It is characterized by the appearance of an erythematous macular eruption affecting the upper limbs in a dependent position and the lower limbs and trunk on standing, which resolves with elimination of gravity (1,2). Berth-Jones and GrahamBrown (1), who observed the appearance of lower limb macular erythema on standing, first described it in 1988 in a 16-year-old girl. In 2003 Perrett et al (2) described the dependent occurrence of this rash in the
© 2015 Wiley Periodicals, Inc.
Brief Report e131
limbs and abdomen of a 27-year-old man that would resolve when he raised his arms or laid flat. Pereira et al (3) noted similar findings in the upper limbs, and Monteiro et al (4) described a 10-year history of this clinical entity in the limbs of a 29-year-old woman. In all cases, the rash could be clinically reproduced by increasing venous pressure using a sphygmomanometer. The physiology of this condition has therefore been postulated to be secondary to an abnormal vascular response to changes in venous pressure. This may be due to ineffective or a lack of normal vasoconstriction on lowering a limb or may be due to functional abnormalities in arteriovenous communication (1,2). Determining the precise occurrence and dependent nature of the rash was important to the diagnosis. Also, its macular appearance and lack of response to antihistamines further differentiated it from urticaria. Clinically it can be reproduced using a sphygmomanometer. No recognized effective treatment for this benign but psychologically frustrating condition has been reported. This is the first case in which compression stockings were used to improve the rash in the lower limbs. Although compression stockings did not
prevent the rash from occurring, they delayed the onset of the rash and therefore were of some benefit to the patient. REFERENCES 1. Berth-Jones J, Graham-Brown RAC. Gravitational erythema. Clin Exp Dermatol 1988;13:259. 2. Perret CM, Berth-Jones J, Dharma B. Gravitational erythema. Br J Dermatol 2003;148:1267. 3. Pereira T, Vieira MD, Fernandes JC et al. Gravitational erythema. Pediatr Dermatol 2007;24:316–333. 4. Monteiro M, Aguiar EA, Boleira Sieiro Guimaraes M et al. Gravitational erythema. J Am Acad Dermatol 2009;60:AB46. Seher Rahmatulla, M.B.B.S., B.Sc. Krisztina Scharrer, M.D. Julia Schofield, M.B.Ch.B. (Honours), M.R.C.G.P., F.R.C.P. Khalid Hussain, M.B.B.S. Neill Hepburn, B.Sc., M.B.Ch.B., M.D. Department of Dermatology, Lincoln County Hospital, Lincoln, Lincolnshire, UK Address correspondence to Seher Rahmatulla, M.B.B.S., B.Sc., Lincoln County Hospital, Lincoln, Lincolnshire, UK, or e-mail: [email protected].
This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material.
