A 45-year-old African-American woman complained of an ulcerating lesion that had been growing on her hand for six weeks. Pain limited her daily activities. OTC topical antibiotics and soothing agents had been ineffective. The patient denied antecedent trauma. Other medical problems included chronic kidney disease (for which she was hemodialysis-dependent), hypertension, anemia, obesity, and hepatitis C infection. She had not been compliant with her dialysis regimen or her medications: darbepoetin alfa (Aranesp), ferrous sulfate, atorvastatin (Lipitor), and amlodipine (Norvasc). On examination, the 2- to 3-cm stellate ulcer and the surrounding discrete punctate purpura were exquisitely tender to light touch. No lymphangitic streaking or lymphadenopathy was noted.


A 55-year-old Caucasian man had recurrent sores and erosions on his hands and forearms bilaterally. First noted about six months before, the problem had been intermittent, occurring more often after he painted the outside of his house. Occasionally, he had noted a blister, but not consistently. The patient reported a six-month history of tea-colored urine and right upper-quadrant pain, which he attributed to his chronic hepatitis C. Although a hepatologist was considering treatment, the man was taking no medications. He admitted to drinking four to six beers a night. Multiple crusted erosions and bullae were seen on the dorsal aspects of both hands and proximal forearms, with resultant scarring. Hypertrichosis was noted over both temples between his eyebrows and hairline.

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