A 62-year-old man presented with a 3-month history of severe, ulcerating skin lesions over the extremities. Painless violaceous macules, livedo, and occasional bullae gave rise to ulcerations after a few weeks. The lower extremities were predominantly involved, with spontaneous amputation of some necrotic digits. The lesions extended proximally over the buttocks. The patient had a 4- to 5-year history of frequent painless traumatic wounds that healed after 2 to 3 weeks, leaving atrophic scars. The patient also noted progressive thickening of the skin, with loss of body hair, especially the eyebrows. Physical examination revealed a chronically ill man with waxy diffuse skin infiltration and a total loss of body hair. Numerous angular ulcerations were located over the extremities (Figure 1) and surrounded by a livedoid pattern. The findings of the rest of his examination were unremarkable except for a sensitive polyneuropathy. Laboratory evaluation showed the following abnormal values: hemoglobin, 90 g/L; mean corpuscular volume, 67 pg; erythrocyte sedimentation rate, 120 mm/h; and serum albumin, 16 g/L. The serum concentration of γ-globulin was increased in a polyclonal pattern. A skin biopsy specimen was obtained (Figure 2), and Ziehl-Neelsen staining was performed (Figure 3).
Hernández FG, Rosa JN, Serra AJ, Rey JP. Diffuse Painless Ulcerations. Arch Dermatol. 1999;135(8):983-b-988. doi:10-1001/pubs.Arch Dermatol.-ISSN-0003-987x-135-8-dof0899