Red, circular rashes on the skin are a telltale sign of ringworm, but your doctor may also test a sample to confirm. In the case of a disease like lupus, the immune system mistakenly attacks the body and damages healthy tissues and organs. Systemic lupus erythematosus (SLE) is the most common type. The rash typically isnt itchy or painful and rarely leaves scars. Last reviewed by a Cleveland Clinic medical professional on 05/26/2022. In: Bolognia JL, Schaffer JV, Cerroni L. Perkins J, Buckland M, Miller RA. RELATED: Diagnosing Lupus: Tests and Screenings, Early Diagnosis, and Your Doctors. This can signal subacute cutaneous lupus. The hallmark finding in urticaria is its transient course. Moriarty B, Hay R, Morris-Jones R. The diagnosis and management of tinea. During an eruption, lesions begin small then extend peripherally, becoming more erythematous over time.32 As lesions mature, desquamation occurs, leaving a collarette of scale at the margin, which often is accompanied by intense pruritis and burning.32,33. It has a lot of mimics, or other conditions that can appear to be butterfly rash, so it needs to be distinguished from those, says Stojan. Raynauds is a reversible vasoconstriction of blood vessels in the fingers that is induced by cold. For most patients, ECM at the site of the tick bite is the first sign of infection.17 However, only about half of patients presenting with ECM will recall a recent bite or exposure to ticks. Sun exposure may produce rashes, including those that are located on the bridge of the nose and cheekbones in those with SLE. People with lupus can have a variety of cutaneous manifestations. Patients might also notice tiny lines on the skin where the mites. In people with subacute cutaneous lupus (SCLE), the rash looks like scaly red patches or ring shapes. Sharply demarcated red to pink to brown patches or thin plaques with greasy scale. During a first-time flare, this rash can resemble ringworm. If a physical cause is suspected, provocative testing can uncover the offending stimuli.14, Treatment for acute urticaria involves avoidance of identifiable triggers and use of first- or second-generation antihistamines.14,21 If the patient fails to respond, a three-week tapered course of systemic corticosteroids is effective with a lower risk of recurrence than shorter courses.14. Lee LA, Werth VP. (2013, June 20). Favors the face, upper trunk, and backs of arms. The minor variant is not associated with systemic symptoms, but EM major is accompanied by symptoms such as fevers and arthralgias.14, EM minor is characterized by distinctive target-shaped or iris-shaped lesions.14 Lesions evolve over several days, beginning as round, sharply demarcated erythematous macules that progress to raised, edematous papules.4 Mature lesions have three distinct zones a dull red center, a pale outlining ring, and an encircling macular erythema.14 (See Figure 11.) (4th edition). 2023 Healthline Media LLC. Learn which joints it usually affects and what you can do to manage the pain. Learn how we can help 5.9k views Reviewed >2 years ago Thank Dr. PHILIP WALLER and another doctor agree You may also have rashes on your forehead, arms, legs or other parts of your body. . Fungus among us? It's a fungal infection that often forms a ring-shaped rash. Diagnosis is based on clinical findings and supported by a recent history of potential exposure. Elewski BE, et al. A dermatophyte is simply a type of fungi that can cause skin, hair, or nail infections. In: Bolognia JL, Schaffer JV, Cerroni L. Griffiths CE, Barker JN. Types of CLE include: Discoid lupus erythematosus (DLE) is the most common form of CLE. This condition causes painful, purple skin patches that worsen in cold temperatures. Hansens Disease. In addition, both can happen almost anywhere on the body, head to toe. Annular LP is a subtype of LP present in 10% of cases and seen scattered among typical lesions described above. Hsu S, Le EH, Khoshevis MR. Notoriously, these infections are caused by dermatophytes, a collective term that describes three genera Microsporum, Trichophyton, and Epidermophyton. can sjogren's or another autoimmune cause rashes and itchiness? Cutaneous lupus erythematosus (CLE) affects the skin. People with CLE develop skin rashes or sores, typically on sun-exposed parts of their body. It is not difficult to tell the difference. You have reached your article limit for the month. Although rashes are not usually an emergency, it is common for emergency physicians to see patients come in with a rash. Sometimes the rash is new onset, and sometimes it has been present for a while and refractory to treatment. Shiohara T, Mizukawa Y. Lichen planus and lichenoid dermatoses. Redness and skin discoloration may take longer to go away. (2013, July 12), How does lupus affect the nervous system? Lesions are characterized by asymptomatic, small, annular papules or plaques with raised borders, typically purple to white in color.24,25 (See Figure 5.) Yes: People with lupus can have a variety of cutaneous manifestations. Lupus can make your skin extremely sensitive to sunlight and other types of light. American Academy of Dermatology Association. It affects many different organs of the body, including the kidneys, lungs, brain, and arteries. Diagnostic usefulness of dermoscopy in differentiating lichen aureus from nummular eczema. Like ringworm, eczema is often first noticed as an itchy, red patch. Free to everyone, these materials teach young people about common skin conditions, which can prevent misunderstanding and bullying. Other symptoms may include: dry skin rough or scaly patches of skin swelling crusting or oozing Unlike ringworm, there's. A small percentage of people will develop both this ring-like rash and the one that looks like eczema or psoriasis. Well-circumscribed, erythematous dry plaques with silvery scale. Chronic urticaria almost always occurs in adults and often does not have an obvious trigger.20 The eruption is composed of wheals, well-defined superficial swellings of the dermis that are characterized by raised, erythematous papules or plaques surrounded by a red flare.21 (See Figure 4.) If you want to diminish a noticeable scar, know these 10 things before having laser treatment. Elsevier, China, 2018: 662-80. There are several different types of skin changes and rashes associated with lupus. It can smooth out deep wrinkles and lines, but the results arent permanent. Annular psoriasis may present similarly, but these lesions have diffuse, thick scaling throughout as opposed to the fine, trailing scale around the margin in EAC. These dermatologists' tips tell you how to protect your skin. Generally, these secondary lesions will not have the targetoid appearance of the primary lesion and will spare the palms and soles.19 The cutaneous manifestations are self-limiting and, if untreated, will fade within six weeks.17, While the skin manifestations are mostly asymptomatic, accompanying symptoms of Lyme disease are common. Images 12,13: Used with permission of theJournal of the American Academy of Dermatology. MD Candidate, Wright State University Boonshoft School of Medicine, Dayton, OH, Richard A. Miller, DO, Program Director, Dermatology Residency Program, Nova Southeastern University College of Osteopathic Medicine/Largo Medical Center, Largo, FL. Cutaneous lupus erythematosus. (2012). my dr ruled out bacteria infection and cold sores. In: James WD, Berger TG, Elston DM. Has circular, coin- or disk-shaped red patches that are thick and scaly. In: James WD, Berger TG, Elston DM. When this patient saw a dermatologist, the doctor immediately began testing for lupus. Allergic urticaria can be IgE-mediated, occurring in response to foods (milk, eggs, wheat, shellfish, nuts), inhalants (pollen, dander), medications (penicillin), or complement-mediated in the case of serum sickness. Genodermatoses and Congenital Anomalies. Dr. Kellawan (author), Mr. Andrasik (author), Dr. Schneider (editor), Dr. Stapczynski (editor), Ms. Light (nurse planner), Ms. Mark (executive editor), Ms. Coplin (executive editor), and Ms. Hatcher (editorial group manager) report no financial relationships with companies related to the field of study covered by this CME activity. Get useful, helpful and relevant health + wellness information, 9500 Euclid Avenue, Cleveland, Ohio 44195 |, Important Updates + Notice of Vendor Data Event, (https://www.aad.org/public/diseases/a-z/lupus-symptoms), (https://www.americanskin.org/resource/lupus.php), (https://www.cdc.gov/lupus/basics/symptoms.htm), (https://www.lupus.org/resources/how-lupus-affects-the-skin), (https://www.lupus.org/resources/the-history-of-lupus), (https://www.lupusresearch.org/understanding-lupus/what-is-lupus/symptoms/), (https://www.merckmanuals.com/home/bone,-joint,-and-muscle-disorders/autoimmune-disorders-of-connective-tissue/systemic-lupus-erythematosus-sle). Tinea corporis produces well-demarcated, erythematous, dry, and scaly lesions with raised red borders and central clearing. Its sometimes itchy but generally isnt painful. Lupus can also lead to pulmonary hypertension, a form of high blood pressure in which the blood vessel connecting the heart to the lungs thickens. Localized granuloma annulare produces annular lesions with smooth, non-scaly contours. In many cases, the diagnosis may not be obvious, even for the experienced clinician. James WD, Berger TG, Elston DM. SCLE is characterized by the rapid appearance of small or large, erythematous to pink-colored plaques with raised borders, central clearing, and an easily detached scale.41,42 The eruption is extremely photosensitive and, thus, most commonly will present on the face, upper trunk, and the backs of the arms.41, In differentiating SCLE from other annular lesions, a history of sun exposure in correlation with the appropriate distribution supports the diagnosis. Okon LG, Werth VP. Lesions are oval-shaped, scaly, skin- to salmon-colored papules or plaques. (n.d.), How does lupus affect the renal (kidney) system? Discoid lupus, a type of cutaneous lupus, causes circular red rashes on your body. Erythema annulare centrifugum (EAC) belongs to a group of disorders characterized by raised, erythematous lesions that form annular, polycyclic, or arcuate arrangements.14 Although the etiology is unclear and most patients do not have an identifiable trigger, an association with leukemias and lymphomas has been reported.15 The eruption is seen in both men and women and peaks in the fifth decade of life.16 Lesions begin as firm, pink papules that expand slowly over weeks, clear centrally, and progress to annular, erythematous, minimally elevated lesions that remain relatively asymptomatic beyond mild pruritis.14,16 Just inside the erythematous border is a trailing white scale that represents desquamation at the inner margin, characteristic of EAC. publications. Your healthcare provider can help you find the best treatments to prevent and treat lupus rashes. As a general rule, individual wheals do not last longer than 24 hours.20 Urticaria may be accompanied by deeper, ill-defined swellings of the dermis and subcutaneous tissue, termed angioedema.21, Urticaria can be classified as allergic, physical, or idiopathic. Most patches appear on the face, scalp, or ears, but patches can develop elsewhere on the skin. Most eruptions spontaneously resolve in two to eight weeks.28 Treatment with anthelmintics can shorten the course of the disease. Lupus is an inflammatory disease that causes a rash to form on the body and, in an initial form, can resemble a ringworm rash. People who have discoid lupus develop these patches. Lupus treatments like immunosuppressants can keep the disease in check, lowering your risk of developing a lupus rash. When you have a butterfly rash, people may think that youre flushing, blushing or have a bad sunburn. They can look like a ring with a darker red circle on the ring's outer edge. While rare, a basic cancer workup is warranted to rule out a paraneoplastic cause. The classic presentation often is alarming to patients, prompting medical evaluation. The rash can also occur on the arms, legs, and body, she adds. Some lesions might look like ringworm with rough, red patches. The chronic nature of the disease often leads to complex treatment regimens requiring combination therapy to achieve control. These sores can feel uncomfortable. By continuing to use our site, you consent to the use of cookies outlined in our Privacy Policy. and article library. The most common type affects young adults, usually on the hands and feet. Lesions are asymptomatic, measuring up to several centimeters in diameter and having a predilection for the hands, fingers, feet, and ankles.31 When multiple lesions are present, they are almost always unilateral and localized.30, Focusing on the furrowed rim formed by the prominent border and depressed center is key in differentiating the lesion from other annular lesions like tinea. A butterfly-shaped (malar) face rash is a common sign of the disease. Morales-Burgos A, Snchez JL, et al. Sometimes hair loss may be permanent. Therefore, referral to a dermatologist is appropriate. Sometimes when people have active systemic lupus, they can have a diffuse loss of hair, says Werth. Bites, stings, and outdoor rashes Many insects can cause a. Healthline has strict sourcing guidelines and relies on peer-reviewed studies, academic research institutions, and medical associations. This review also may be helpful especially in cases of suspected tinea that are refractory to treatment. Among the common presentations seen on a day-to-day basis are annular lesions. The ACLE rash is very sensitive to light. Jock itch: Tinea cruris, or jock itch, causes a red, itchy rash in your groin, upper thighs or rectum. James WD, Berger TG, Elston DM. As a general rule, the individual lesions last less than 24 hours. For DSR inquiries or complaints, please reach out to Wes Vaux, Data Privacy Officer, Normally, the immune system protects the body against foreign invaders like viruses and bacteria. Retrieved from, How does lupus affect the heart and circulation? In: James WD, Berger TG, Elston DM. With proper treatment for lupus, this lost hair often grows back. Sometimes the rash is new onset, and sometimes it has been present for a while and refractory to treatment. Mario J. Sequeira, MD, FAAD, Dermatologists team up to improve patient care, JAK inhibitors: A newer type of medication, Free materials to help raise skin cancer awareness, Dermatologist-approved lesson plans, activities you can use. Tuberculoid erythematous plaques with raised, sharply defined borders and atrophic center. Consider one of the subscription options below to receive full access to this article and many more. Retrieved from, What causes hemolytic anemia? It looks like ringworm and usually appears on the torso. is this diagnosis wrong? Clinically, NE follows a chronic course characterized by well-demarcated, erythematous, or hyperpigmented coin-shaped plaques with diffuse crust.37 (See Figure 9.) However, treatment generally is not required, as the eruption spontaneously remits in three to eight weeks.12 If patients experience intense pruritus, second-generation antihistamines, topical corticosteroids, a short course of systemic corticosteroids, or narrowband ultraviolet B (UVB) phototherapy can provide symptomatic relief.10. Discoid lesions on your scalp may cause temporary or permanent hair loss. The signs and symptoms of lupus that you experience will depend on which body systems are affected by the disease. If you already have a subscription to this publication, please. Naldi L, Gambini D. The clinical spectrum of psoriasis. The most common type of lupus, systemic lupus erythematosus (SLE), can cause dry, coarse hair to develop along the hairline. Video chat with a U.S. board-certified doctor 24/7 in less than one minute for common issues such as: colds and coughs, stomach symptoms, bladder infections, rashes, and more. Often people feel pain and stiffness in their joints, which is called lupus arthritis. Some lesions might look like ringworm with rough, red patches. Discoid lupus causes raised, scaly patches. Policy. Scars are often permanent, although they may fade over time or with treatments. Weston G, Payette M. Update of lichen planus and its clinical variants. Pathogenesis and clinical features of psoriasis. Can you have lupus without any sort of rashes? Find out how a board-certified dermatologist helped Natalie see clear skin before her wedding. When you have subacute cutaneous lupus, red borders develop around the edges of these lesions. my face gets red daily & occasionally extra redness in shape of butterfly rashes. Favor the face, neck, and areas of trauma. Our All Access Subscription provides unlimited access to our entire publication Lichen Planus and Related Conditions. To learn why someone may get any type of lupus, go to:Lupus and your skin: Causes. These are most common in people who have systemic lupus erythematosus (SLE). In: James WD, Berger TG, Elston DM. If you have what feels like razor bumps or acne on the back of your neck or scalp, you may have acne keloidalis nuchae. Sometimes, a rash or other sign of lupus causes a symptom like itch or pain. Wont scar but might lighten or darken your skin. Physical urticarias include dermatographic urticaria, occurring where skin has been stroked; cholinergic urticaria, occurring in response to fever and hot baths; cold urticaria, occurring on distal extremities upon rewarming; pressure urticaria, often occurring on the feet and buttocks hours after pressure has been applied; solar urticaria, occurring after exposure to light; and exercise-induced urticaria, which presents with large lesions five to 30 minutes into exercise.14, Urticaria is a clinical diagnosis based on history and physical exam. It can be mistaken for psoriasis or eczema. First- or second-generation antihistamines. Lesions may appear annular when they develop rapidly, forming the active outer margin first, leaving relatively normal skin at the center.34 As plaques regress, margins persist while the center heals, again resulting in annular-shaped lesions.35 (See Figure 8.) Discoid sores on your lips or inside of your mouth may develop a type of skin cancer called squamous cell carcinoma. Ring-shaped rash In people with subacute cutaneous lupus (SCLE), the rash looks like scaly red patches or ring shapes. What does a lupus rash look like on darker skin? Pityriasis rosea: A comprehensive classification. Interested in Group Sales? About 90 percent of patients who get malar rash have systemic lupus. Media community. Red to pink plaques with raised borders and central clearing. With round rashes, my differential was limited to tinea, if it had been there for a while, or urticaria and erythema multiforme, if it had just started. We do not endorse non-Cleveland Clinic products or services. This type of reaction indicates that your skin is photosensitive. There are two kinds of changes that can happen around the nails in lupus. Rarely, patients experience a chronic course lasting longer than six weeks or progress to anaphylaxis.21 In acute cases, a trigger such as infection or allergic reaction may be identified. We will certainly can sitter a variety of possibilities. Psoriasis is suggested when lesions occur on the extensor surfaces of the limbs, umbilical region, and sacrum. Consider one of the subscription options below to receive full access to this article and many more. The trusted source for healthcare information and CONTINUING EDUCATION. Apply UV-protective window films to your car windows. Cutaneous LP often is self-limiting; most cases resolve spontaneously within one year.24 For cutaneous disease, topical corticosteroids under occlusion can be used.24,25 When lesions are symptomatic or when oral lesions are present, intralesional triamcinolone is helpful.25 Widespread disease can be treated with systemic corticosteroids, although relapse may occur when the dose is tapered.25, Cutaneous larva migrans is a serpiginous eruption caused by animal hookworm larvae as they migrate through the epidermis.26 In the United States, this disease is most common in warm, southeastern states.27 Percutaneous infection often occurs in those who walk barefoot and children who play in sandboxes. Erythema and Urticaria. Lupus occurs when cells in your immune system that typically fight off infections turn against your body and attack healthy cells. Advertising on our site helps support our mission. Malar rash is a classic photosensitive rash; it tends to be induced by sun exposure, says Stojan. The most common type, chronic plaque psoriasis, accounts for approximately 90% of cases.34 In this variant, lesions present as well-circumscribed, erythematous, dry plaques covered by a silvery scale. The term annular is derived from the Latin word annulus, meaning ring shaped.1 These lesions have a characteristic appearance, described as round to oval-shaped patches or plaques with central clearing. Lupus Erythematosus. Top answers from doctors based on your search: Created for people with ongoing healthcare needs but benefits everyone. In lupus, the immune system can damage healthy red blood cells. How do lupus rashes start out? For small, localized lesions, potent topical corticosteroids and vitamin D derivatives in creams, lotions, or ointments can be used.32 When plaques persist, intralesional injections of triamcinolone can be tried.32 Another commonly used, cost-effective modality is phototherapy.32 When the disease is severe or widespread, biologic and oral immunosuppressive agents are options. Linger for weeks or get worse despite treatment. Treatment can help get rid of these symptoms until your skin clears. Damage, such as scarring, hair loss, and lighter and darker skin, could be permanent in cases of discoid lupus. Drago F, Ciccarese G, Rebora A, et al. Inflammation throughout your body causes symptoms like lupus rashes, joint pain, extreme fatigue and fever. Lupus that affects the skin (CLE) comes in different forms, and causes different types of rashes. Heres what you need to know about how your rheumatologist can help you deal Lupus is a chronic autoimmune disease that can have serious consequences. The smaller lesions are usually on the torso or wherever the herald patch is located. Images 14-15: Used with permission ofDermNet NZ. In: Bolognia JL, Schaffer JV, Cerroni L. James WD, Berger TG, Elston DM. Typical and atypical clinical appearance of atopic dermatitis. "Candida is a yeast," says Weinberg . Within days, erythematous papules followed by characteristic thin, red, torturous tracts begin to appear.26 (See Figure 6.) What it looks like: Scabies is a discolored, splotchy rash that can appear pimple-like on any affected parts of the skin. Knowing what to watch out for detailed below can help you manage and treat these conditions. By using our website, you consent to our use of cookies. Leukemia and its associated treatments may cause skin-related side effects. utis? ringworm? Large, evolving erythematous plaque without scale. Psoriasis. Navarro-Trivio FJ, Ruiz-Villaverde R. Chronic discoid lupus: An uncommon cause of nail atrophy. Sultan Qaboos Univ Med J. Symptoms, Causes, Diagnosis, and Treatment, Lupus Treatment: Medications and Complementary Therapies, Types of Lupus: Symptoms, Diagnosis, Treatment, What Causes Lupus? If you have discoid lupus, hair loss can be permanent because scarring develops. Prompt treatment of discoid lupus on the scalp can prevent scarring. Other rashes can look like ringworm, including spider. Whats the Connection Between Lupus and Anemia? A dermatologist is a medical doctor who specializes in treating the skin, hair, and nails. Multiple firm, red to purple to brown colored papules, nodules, or plaques. Urticaria and Angioedema. Technically speaking, " ringworm is a dermatophyte," says Weinberg. Put up UV-protective window coverings at home and work. When lupus attacks the lungs, it can cause trouble breathing. Because less blood can travel from the heart to the lungs to pick up oxygen, the heart has to work much harder to keep up. Use these professionally produced online infographics, posters, and videos to help others find and prevent skin cancer. Calluses, common warts, and other benign conditions can all cause hard. Other triggers include drugs (penicillin, phenytoin, allopurinol, sulfonamides, barbiturates) and Mycoplasma infections.14 Erythema multiforme can be separated into EM minor and EM major, the more severe form with mucosal involvement. Other Papulosquamous Disorders. Ivermectin (adults)/albendazole (children). Benign Epidermal Tumors and Proliferations. Your physician can differentiate these from . There are many rashes from lupus but people with lupus can also get rashes that ar Dr. PHILIP WALLER and another doctor agree. Like you, Ive had little training in dermatology; most of what I know was learned on the job and through continuing education. It's most common in men and adolescent boys. Lesions are mildly pruritic and oriented along cleavage lines.12 When stretched, scale hangs, resulting in the pathognomonic hanging curtain sign. Multiple lesions may coalesce, forming a diffuse rash that, when present on the back, exhibits a Christmas tree pattern along Langers lines, the natural folds of the body. ( 8) Other. Find out why dark spots appear and what can fade them. Often associated with a scaly, palpable edge. To diagnose EM, several lesions must evolve into the classic, target-shaped ones described above.43 In addition, EM lesions remain fixed for multiple days, whereas individual urticarial lesions last less than 24 hours. Key morphological characteristics of annular lesions can improve diagnostic accuracy, leading to correct initial treatment. For potential or actual medical emergencies, immediately call 911 or your local emergency service. They appear most often on the neck, chest, upper back, shoulders and arms. Superficial mycotic infections are those limited to keratinized environments such as the skin, hair, and nails. Establishing a broad differential and focusing on key morphological characteristics will improve accuracy of diagnosis, limit unnecessary treatment, and lead to faster resolution of disease. Lepromatous numerous, poorly defined, hypopigmented macules that are symmetrically distributed. Let's look at the support available to you: Yes, about 1 in 10 of the people with lupus are men or assigned male at birth. Should I look out for signs of complications? More than 90 percent of people with lupus will experience joint pain and weakness, according to the Lupus Foundation of America. In adults, the most common etiology of annular lesions is tinea, a superficial fungal infection of keratinized tissue. Approximately two out of every three people withlupus will develop some type of skin disease, known as cutaneous lupus erythematosus, according to the Lupus Foundation of America. Should people with lupus stop taking medications before getting their shots? The hair loss may be patchy or widespread. Centrally, lesions lack the associated crusts or vesicles commonly seen with tinea. This patient developed a lupus rash after spending time under fluorescent lighting. Well-circumscribed, non-scaly edematous papules or plaques with blanched centers, surrounded by a red flare. Other conditions that occasionally look like ringworm include seborrhea, psoriasis, pityriasis, contact dermatitis (such as poison oak), drug reactions, tinea versicolor, vitiligo, erythema migrans (a rash seen in Lyme disease), and even lupus. Pityriasis rosea produces diffuse eruption on the trunk and proximal extremities with oval-shaped, scaly plaques. Non-scaly, erythematous to violaceus colored papules or plaques with a thin, smooth border. The rash is distinctive for its butterfly-like appearance: It spreads across the nose and fans out on both cheeks. In naming dermatophyte infections, the term tinea is used, followed by the Latin name for the anatomical area infected.2 Subtypes include tinea corporis (body), cruris (groin), capitis (scalp), faciei (face), barbae (beard), unguium (nail), and manuum (hand). In: James WD, Berger TG, Elston DM. Although characteristic plaques predominate, variations in morphology are not uncommon. ACLE causes the facial butterfly rash (malar rash). Ringworm Look-Alikes: A Host of Less Common Culprits. Doxycycline (adults)/amoxicillin (pregnant women and children). Butterfly or malar rash is a kind of acute cutaneous lupus, according to Stojan. Shape varies, but lesions often are round and blanch centrally, conferring an annular appearance.14 Lesions range from a few millimeters to more than 10 cm in size and are accompanied by intense itching, stinging, or burning. Lesions of discoid lupus erythematosus vary greatly; however, they rarely are annular.
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