Multiple granulomatous dermatitides in a patient with rheumatoid arthritis

CASE REPORT A woman in her 70s was referred for a 20-year history of progressive skin disease consisting of annular plaques on her trunk and extremities, atrophic plaques on her legs, and painful subcutaneous nodules on her hands and feet (Fig 1). She complained of mild shortness of breath, polyarthralgias, and numbness and tingling of the lower extremities consistent with a sensory peripheral neuropathy. She had 2 episodes of ocular necrotizing scleritis that resolved with high-dose prednisone. Physical examination found extensive pink scaly annular plaques on her upper back, arms, and legs; nodules on the dorsal hands and fingers overlying joints; and atrophic, orange-brown and hyperpigmented plaques on the lower shins as well as a symmetric polyarthritis. She also had transient red-brown subcutaneous nodules on the lower legs. Laboratory blood analysis found a leukocyte count of 18.5 thousand/ L (normal, 3.8e10.8 thousand/ L) with a serum eosinophilia count of 4736 cells per microliter (normal, 15e500 cells per microliter) and high-sensitivity C-reactive protein