Rash on lower extremities

Presenter: Susun Bellew, DO; Grace K. Kim, DO; Saira Momin, DO; Brent Michaels DO
Dermatology Program: Valley Hospital Medical Center, Las Vegas, Nevada
Program Director: James Q. Del Rosso, D.O.
Submitted on: Jan 30, 2010

CHIEF COMPLAINT:  A 62-year-old Italian man presented to the office for evaluation of a “rash” that started on his lower extremities.


Signs and symptoms:  Patient reports a persistent eruption for 4 years that originally started on his lower extremities which progressed to his arm, palms, and low back (Fig 1 and Fig 2). He also reported occasional pruritus of the lesions which was not severe. The patient and his wife both denied any suspected precipitating factors. He also denied constitutional symptoms such as fever, chills, weight loss, myalgia, or arthralgia.

Previous Treatment:  The lesions were previously treated with topical triamcinolone 0.1% cream with no clinical improvement.

Other information:  Past medical history was significant only for Parkinson’s disease. There was no known history of other major medical disorders, such as metabolic diseases or malignancies. He also denied recent travel or history of any sexually transmitted diseases, including syphilis. No other family members or close personal contacts were afflicted with similar lesions.


Examination revealed numerous symmetric 1-5mm red-brown scaly, focally keratotic papules on his lower legs and feet. Other anatomic regions of involvement included the arms, palms, abdomen, and back. Importantly, the lesions were monomorphic in appearance overall. No excoriations, vesicles, pustules or burrows were noted. The face, neck, and scalp were spared, and no lesions were noted on his genitalia. Removal of the scales resulted in pinpoint bleeding. Oral mucosa, hair and nails were not affected. There was no cervical, axillary, or inguinal lymphadenopathy.


Figure 1 Diffuse scaly pink papules distributed symmetrically on bilateral legs


Figure 2 Lesions present on bilateral palms


A 4mm punch biopsy was obtained from one of the lesions and sent for histological analysis.


Histopathologic examination revealed a band-like infiltrate of lymphocytes and histiocytes. There was also exocytosis of lymphocytes into the overlying epidermis, with mild spongiosis with focal vacuolar alteration of the basal layer keratinocytes. In addition, there was an absence of the granular layer with overlying compact orthokeratosis and focal parakeratosis. Epidermal thinning with flattened rete ridges were also observed. The adjacent epidermis revealed preservation of granular layer with overlying basket-weave orthokeratosis (Fig 3 and Fig 4).

Figure 3 Basket-weave orthokeratosis and an adjacent area showing thicker epidermis with a preserved granular layer. Hematoxylin-eosin stained and 10x magnification

Figure 4 Slight compact orthokeratosis, absence of granular layer, and band-like infiltrate of lymphocytes with spongiosis. There is epidermal thinning and flattened rete ridges. Hematoxylin-exosin stained and 10x magnification


1.   Acrokeratosis verruciformis of Hopf
2.   Actinic keratosis
3.   Hyperkeratosis lenticularis perstans (Flegel’s disease)
4.   Hyperkeratosis follicularis et parafollicularis in cutem penetrans (Kyrle’s disease)
5.   Keratosis follicularis (Darier’s disease)

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