Burning and stinging red nodules on the dorsum of hands

Presenter: Jessica Vincent, DO
Dermatology Program: OhioHealth O’bleness Hospital
Program Director: Dawn Sammons, DO, FAOCD
Submitted on: Apr 13, 2016

CHIEF COMPLAINT:  A 57 year old male presented to the current authors complaining of burning and stinging red nodules on the dorsum of his hands for about 1 year.


Signs and symptoms:  He also admitted to persistence of an episodic rash over the lower legs and bilateral flanks he had originally presented with 7 years prior.

Previous Treatment:  He was briefly treated with an oral prednisone taper and topical corticosteroids including triamcinolone 0.1% cream and clobetasol 0.05% cream without improvement.

Other information:  A biopsy 7 years prior revealed leukocytoclastic vasculitis (LCV) with prominent eosinophils. At the time, it was felt his skin findings were a manifestation of drug hypersensitivity, likely to opioid use. The patient was subsequently lost to follow up.


On exam were deep red to violaceous discrete nodules and plaques with overlying hyperkeratosis involving all distal and proximal interphalangeal joints of the hands and extensor elbows. On the bilateral posterior arms, anterior legs and periumbilical area were deeply erythematous papules and plaques with background hyperpigmentation. Across his low back and bilateral flanks were erythematous papules with central hemorrhagic crusting.


Red-brown indurated nodules over extensor joint surfaces with superficial scale


Periumbilical reticulate hyperpigmented patch


Pertinent laboratory findings included a positive hepatitis B surface antigen with hepatitis B DNA value 4313876 IU/mL and a HBV quantitative PCR value of 6.64 units (reference range <1


Three 4-mm punch biopsies were performed from the left 5th digit, left posterior arm, and left flank. Tissue of the left 5th digit showed an intradermal vascular proliferation with a concentric, “onion skin” pattern in a background of increased fibrosis. The blood vessels showed focal fibrinoid necrosis. The biopsy of the left posterior arm showed an intradermal vascular proliferation with an associated mild acute and chronic perivascular inflammation. The left flank biopsy showed showed leukocytoclastic vasculitis with focal epidermal necrosis.


1.   Henoch-Schonlein purpura
2.   Cryoglobulinemia
3.   Sarcoidosis
4.   Multicentric reticulohistiocytosis
5.   Livedoid vasculopathy

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