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JAMA Clinical Challenge
March 4, 2019

A 22-Year-Old Man With Painful Vesicles on His Flank

Author Affiliations
  • 1Center for Clinical Studies, Webster, Texas
  • 2Department of Dermatology, University of Texas Health Science Center at Houston
JAMA. 2019;321(12):1213-1214. doi:10.1001/jama.2019.0107

A 22-year-old man presented with an 8-year history of painful and slightly pruritic skin lesions on his right flank. The number of lesions and degree of pain had alternately increased and decreased over the years. Occasionally the lesions would rupture and leak clear fluid. One year prior, he was hospitalized for a “skin infection” on his right flank and treated with intravenous antibiotics. The patient, a construction demolition worker, was otherwise healthy and took no medications. He had 1 lifetime female sexual partner with whom he used barrier contraception. Physical examination revealed an asymmetric cluster of lesions on the right flank measuring 14 × 12 cm at the widest margins (Figure 1). The cluster contained verrucous papules and plaques in the center and vesicles filled with clear and milky-white fluid in the periphery. Crust was partially covering some of the lesions. The surrounding skin was erythematous without warmth or induration. The remainder of the physical examination was normal except for stretch marks on the lateral abdomen.