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June 2010

Painful Vesicles on the Wrist—Quiz Case

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Arch Dermatol. 2010;146(6):667-672. doi:10.1001/archdermatol.2010.117-a

A 20-year-old Marine presented with a 1-week history of a painful lesion on his wrist. It began as grouped vesicles on an erythematous base that became pustular. The lesion continued to expand and became indurated, so incision and drainage was attempted in the emergency department, followed by intravenous administration of 1 g of vancomycin. The patient was discharged with a prescription for oral trimethoprim sulfamethoxazole.

However, he returned the following day because of progression of the erythema and pain. On physical examination, a 4 × 2-cm targetoid plaque was noted on the right dorsomedial aspect of the wrist. Centrally it had a grayish hue, and peripherally it was more violaceous. The area surrounding the lesion and extending up the medial forearm was erythematous and edematous (Figure 1). Other than tender right axillary lymphadenopathy, the remainder of the examination findings were unremarkable. A punch biopsy specimen was taken from the periphery of the lesion (Figure 2).

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