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November 17, 2008

Follicular Eruption on Arms and Legs—Quiz Case

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Copyright 2008 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2008

Arch Dermatol. 2008;144(11):1509-1514. doi:10.1001/archderm.144.11.1509-a

A 17-year-old boy with congenital absence of the intrahepatic bile ducts owing to Alagille syndrome presented with a pruritic eruption of 3 months' duration. He also reported a new problem, seeing “dark spots” at night. His medical therapy included bile acid–binding resins and supplementation of fat-soluble vitamins. His chronic jaundice was unchanged. Physical examination revealed jaundice and numerous 2- to 8-mm follicular, keratotic erythematous papules on the distal extensor surfaces of his arms and legs (Figure 1). His vitamin A level was 11 μg/dL (reference level, 26-72 μg/dL), and his β-carotene level was less than 2 μg/dL (reference level, 9-190 μg/dL). (To convert vitamin A and β-carotene to micromoles per liter, multiply by 0.0349 and 0.01863, respectively.) Treatment resolved his lesions and vision changes. A punch biopsy specimen was obtained from the forearm for histopathologic evaluation (Figure 2 and Figure 3).

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