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JAMA Dermatology Clinicopathological Challenge
July 2016

Abrupt Onset of Ulcerative Papules and Nodules on the Face and Genitals

Author Affiliations
  • 1Department of Dermatology, Howard University Hospital, Washington, DC
  • 2The Wright Center for Graduate Medical Education, Washington, DC
  • 3Veterans Affairs Medical Center, Washington, DC
JAMA Dermatol. 2016;152(7):829-830. doi:10.1001/jamadermatol.2016.0017

A man in his 60s with a medical history of hypertension, cerebrovascular accident, colon cancer, and remote cocaine use presented with numerous pruritic crusted papules and nodules on the face and genitals. The eruption presented abruptly over a 2-week course, and the patient attributed it to contact with plants while working in his yard. He denied having similar lesions in the past. He had used over-the-counter topical antibiotic and antihistamine creams, which alleviated the pruritus. He denied recent sexual intercourse, penile discharge, fevers, chills, nausea, or vomiting. Physical examination of the bilateral cheeks, glabella, dorsal nose, and chin revealed multiple skin-colored papules, nodules, and vegetative plaques ranging in size from 4 to 6 mm in diameter, with central umbilication, erosions, and overlying yellow crust (Figure, A). There were similar lesions on the scrotum and inner thighs, with sparing of the penis (Figure, B). There was also a 1-cm ulceration on the left lower lip. The palms and soles were spared. There was no lymphadenopathy noted. One 4-mm punch biopsy specimen was obtained from a nodule on the left medial cheek, bisectioned, and sent for both hematoxylin–eosin staining and tissue cultures for bacteria, fungi, and atypical mycobacteria (Figure, C and D).

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