A man in his 30s had ulceration of the skin of the soles, legs, hands, elbow joints, and face of 15 days’ duration. It had started as swelling of the feet, followed by erythematous acral lesions. Numbness of the hands and feet had begun 1½ years previously, spreading gradually to the forearm and legs. He had no history of fever, joint pains, or epistaxis. Black eschar and ulceration with purulent discharge was seen over the soles and elbows. There were triangular and bizarre purpuric and necrotic lesions over the legs, thighs, and dorsum of the hands (Figure, A) with necrosis of pinnae and nasolabial folds. The scrotum was also affected. There was diffuse infiltration of the face and madarosis of the lateral half of the eyebrows. He also had hypoesthesia over the palms, proximal forearms, feet, and legs. Peripheral nerve examination revealed thickening of the right radial cutaneous and both ulnar nerves. Bilateral inguinal lymphadenopathy was present. Findings from the rest of the general physical and systemic examination were normal. Punch biopsy specimens were obtained (Figure, B-D).
Gera S, Ramesh V. Necrotic and Ulcerated Plaques Over Face and Extremities. JAMA Dermatol. 2016;152(3):333-334. doi:10.1001/jamadermatol.2015.4687