PMC4809474_01
Clinical findings, pretreatment. A, Necrotizing scleritis of the left eye. B, Pink, scaly annular plaques on the upper back. C, Firm nodules on the dorsal hands. D, Atrophic, hyperpigmented plaques on the bilateral anterior legs.
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A woman in her 70s was referred for a 20-year history of progressive skin disease consisting of annular plaques on her trunk and extremities, atrophic plaques on her legs, and painful subcutaneous nodules on her hands and feet (Fig 1).
Histopathologic features. A, Histologic examination of the annular plaques on the upper back shows a palisaded histiocytic granuloma surrounding a focus of mucinous necrobiosis within the superficial to mid dermis (original magnification x10). B, Biopsy of a nodule on the right lower leg shows a septal panniculitis (original magnification x5). C, Histologic analysis of the nodules on the dorsal hands shows homogenous eosinophilic material with a palisade of histiocytes (original magnification x5). (A-C, Hematoxylin-eosin stain; original magnifications: A, x10; B and C, x5.)
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Histologic examination of the annular plaques and nodules on the dorsal hands and upper back found palisading granulomatous inflammation with mucinous degeneration of collagen consistent with granuloma annulare, whereas biopsy findings of the nodules on the right lower leg were consistent with erythema nodosum (Fig 2, A and B). Histologic evaluation of the papules overlying the joint spaces found palisaded histiocytes around eosinophilic material consistent with rheumatoid nodules (Fig 2, C).
Clinical findings, posttreatment. A, Upper back, significant improvement of granuloma annulare. B, Bilateral dorsal forearms and hands, significant improvement of granuloma annulare and rheumatoid nodules.
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She was treated with methotrexate, 22.5 mg weekly, pentoxifylline, 400 mg twice daily, and triamcinolone acetonide ointment with significant improvement in her cutaneous disease and other symptoms (Fig 3).