PMC4564610_01
(a) Erythematous macules, papules, and pustules on the trunk. (b) Histopathology of the skin lesion showing parakeratosis, extension of infiltrate into epidermis, vacuolization of basal layer with necrotic keratinocytes, and mixed inflammatory cell infiltration around the vessels and in the upper dermis (HE x200). (c) Necrotic ulcers, erythematous papules, and plaques on the limbs. (d) Clinical appearance after six doses of methotrexate. (e) Clinical appearance five months after the patient's initial visit.
CRIDM2015-357973.001.jpg
PMC4564610_01_CRIDM2015-357973.001.jpg
fig1
Dermatological examination revealed a widespread polymorphic rash with erythematous macules, papules with a central punctum, and pustules on the trunk and extremities (Figure 1(a)). The skin biopsy taken from the body lesion revealed parakeratosis in the epidermis with neutrophil groups within, mixed inflammatory cell infiltration around the vessels and the interstitial area in the upper dermis, and vacuolar degeneration in the basal layer (Figure 1(b)). The liver function test results recovered to normal limits 10 days after discontinuation of erythromycin, but the patient continued to develop new ulceronecrotic lesions (Figure 1(c)). There was marked improvement in the lesions at the 6th week of methotrexate treatment (Figure 1(d)). The lesions healed with a postinflammatory hyperpigmentation and hypertrophic scar (Figure 1(e)).