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A 32-year-old male with a history of end-stage liver disease secondary to alcoholic cirrhosis was transferred to our hospital with a 2-week history of a skin rash that developed at an outside facility where he was being treated for hepatic encephalopathy. He reported that the lesions began on his face, then spread to his thighs and were mildly pruritic. He did not have any other involvement and was in no pain. On physical exam, multiple 1 to 3 cm purple papules with central black and hemorrhagic crusting were noted on his forehead, bilateral cheeks, and anterior thighs (Figure 1, A and B). On his left flank, he had a large polycyclic, atrophic hyperpigmented plaque with a slightly erythematous and scaly border (Figure 1C). The scalp, oral mucosa, back, chest, abdomen, arms, palms and soles were all spared. Multiple toenails were noted to be dystrophic with hyperkeratotic subungual debris. Over the next few days, the crusted papules and nodules eroded leaving smooth erythematous plaques with punched-out centers. Testing for the human immunodeficiency virus (HIV) and hepatitis was negative. Punch biopsy specimens from the left anterior thigh were taken for histopathologic analysis and fungal, bacterial, and atypical mycobacterial tissue cultures. A skin culture was obtained of the polycyclic plaque on his left flank.
Laska AJ, Miller WA, Dominguez AR. Purple Crusted Nodules in a Patient With End-stage Liver Disease. JAMA Dermatol. 2016;152(8):941-942. doi:10.1001/jamadermatol.2016.0935