Erythema gyratum repens

EGR; "wood-grain" eruption; "zebra-skin" eruption; "Gammel disease" (older eponym after John Gammel's 1952 description in a patient with breast cancer)

Erythema gyratum repens is a rare but visually striking paraneoplastic figurate erythema described in 1952 by John Gammel. The eruption presents as concentric, parallel, gyrate, annular bands of erythema with a distinctive trailing fine scale that migrate over the trunk and extremities at a rate of ~1 cm per day, producing a characteristic "wood-grain" or "zebra-skin" appearance widely regarded as one of the most pathognomonic skin signs of internal malignancy. Approximately 80% of cases are paraneoplastic, with lung carcinoma the leading association (~30%) followed by oesophageal, breast, gastric, cervical, prostate, bladder and other carcinomas. The eruption typically precedes cancer diagnosis by 6–12 months and resolves with successful tumour treatment, recurring with cancer relapse — a sensitive clinical marker of disease activity. Recognition of EGR by the dermatologist mandates urgent comprehensive cancer workup.

CurrentLast reviewed 26 April 2026

Clinical features

Concentric, parallel, annular and gyrate bands of erythema with a fine peripheral trailing scale, producing a striking "wood-grain" / "zebra-skin" / "tigroid" appearance.
Lesions migrate over the trunk and extremities at ~1 cm per day; constant change.
Distribution — trunk and proximal extremities; spares face, hands and feet.
Often pruritic.
Median age 50–70; M>F ~3:1.
Associated features — palmoplantar keratoderma, ichthyosis, eyebrow loss in some.
Differential — erythema annulare centrifugum (slower migration, narrower rings, less striking pattern), urticaria multiforme, tinea corporis, mycosis fungoides (figurate variant), urticaria, secondary syphilis, drug eruption.

Underlying malignancies

Paraneoplastic in ~80% of cases:
- Lung carcinoma — the leading single association (~30%) — particularly bronchogenic adenocarcinoma and squamous cell carcinoma.
- Oesophageal carcinoma.
- Breast carcinoma.
- Gastric, colorectal carcinoma.
- Cervical, prostate, bladder, renal carcinoma.
- Lymphoma, multiple myeloma — small minority.
Non-paraneoplastic causes (~20%) — pulmonary tuberculosis, CREST syndrome, drug reactions (azathioprine, lenalidomide), pregnancy, idiopathic.
EGR typically precedes cancer diagnosis by 6–12 months.

Histology

Non-specific superficial perivascular lymphohistiocytic infiltrate.
Mild spongiosis and parakeratosis (corresponding to the trailing scale).
Sometimes mild interface change.
Histology cannot distinguish EGR from other figurate erythemas — diagnosis depends on the characteristic clinical picture and identification of the underlying malignancy.
Direct immunofluorescence — negative.

Cancer workup

Full history and examination — particularly respiratory, gastrointestinal, weight loss, smoking history.
FBC, U&E, LFT, calcium, ESR / CRP.
Urinalysis.
Stool occult blood test / FIT.
CT chest, abdomen, pelvis — first-line; lung carcinoma is the principal target.
Tumour markers — CEA, CA19-9, CA15-3, CA125, AFP, PSA (guided by symptoms).
Mammography (women); cervical screening.
Upper GI endoscopy and colonoscopy in selected patients.
Whole-body PET-CT — increasingly used.
Refer to lung / oncology MDT urgently.

Management

Treat the underlying malignancy — EGR resolves with successful cancer treatment within weeks; recurrence of EGR may signal cancer relapse.
Symptomatic skin care:
- Bland emollients.
- Topical corticosteroids — limited efficacy.
- Topical / oral retinoids — limited efficacy.
- Antihistamines for pruritus.
- Phototherapy — limited evidence.
If exhaustive workup is negative — repeat at 6 and 12 months; EGR may precede cancer diagnosis by months to years.
Multidisciplinary cancer care.