A 60-year-old African American woman presented with a pruritic eruption on her trunk and extremities. Her medical history was remarkable for type 1 diabetes mellitus and hypertension. Her medications included lisinopril, insulin, and estrogen.
Physical examination revealed scattered 0.5- to 1.0-mm, violaceous, flat-topped papules and plaques on the chest, upper back area, and dorsal aspect of the hands. The oral mucosa and nails were unremarkable. The results of routine laboratory examinations, including a complete blood cell count, renal function tests, and urinalysis, were normal. A hepatitis panel was negative. The eruption progressed over the following 4 months despite discontinuation of the patient's lisinopril therapy and treatment with 0.05% betamethasone cream, intramuscular triamcinolone, cyclosporine, and narrowband UV-B. After the sixth phototherapy treatment, a 2.0-mm tense vesicle was noted on the left lower extremity (Figure 1) in an area of previously unaffected skin. Two biopsy specimens of the papular lesions were sent for routine histologic analysis (Figure 2). A biopsy specimen of perilesional skin was sent for C3 direct immunofluorescence after the vesicle was noted (Figure 3).
Lee J, Dasher M, Stadecker MJ, Sobell JM. Vesicles in a Patient With a Lichenoid Eruption—Quiz Case. Arch Dermatol. 2003;139(10):1363-1368. doi:10.1001/archderm.139.10.1363-a