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March 2007

Persistent Violaceous Papules on the Ears—Quiz Case

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Arch Dermatol. 2007;143(3):417-422. doi:10.1001/archderm.143.3.417-b

A 77-year-old white woman presented with a 15-year history of painful hemorrhagic lesions on her ears (Figure 1). The lesions initially had appeared as erythematous macules and telangiectasias that seemed more prominent in cold weather. The patient stated that she had photosensitivity and intermittent arthritis but denied other constitutional symptoms. The differential diagnosis included cutaneous lupus erythematosus, dermatomyositis, photodermatitis, collagen vascular disease, and cryoglobulinemia. The findings of a biopsy were equivocal, showing a dense, homogeneous dermal lymphoid infiltrate. The results of laboratory investigations, including antinuclear antibody, rheumatoid factor, SS-A, SS-B, and cryoglobulin studies, were all negative. Serum protein electrophoresis demonstrated no abnormalities. A complete blood cell count and computed tomography of the chest, abdomen, and pelvis did not reveal systemic disease. The impression was that the infiltrate was reactive, and the patient was treated with hydrocortisone valerate cream. Over the years, the lesions continued to recur, becoming more papular and persistent. Additional biopsy specimens were obtained and stained with hematoxylin-eosin (Figure 2 and Figure 3) and for CD20.

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