Erythematous vesiculopapular eruptions on the extremities

Abstract

A 64-year-old woman presented with a 2-year history of recurrent itchy vesiculopapular eruptions on her extremities. On physical examination, vesicles and erosions with crust were observed on both legs and both arms (Fig. 1). The patient had a 10-year history of seropositive rheumatoid arthritis (RA), and numerous therapeutic agents had been used to control it, including methotrexate 10 mg weekly and systemic steroid (5 mg daily). Aggravation of arthritis usually preceded the development of the skin lesions, which were not accompanied by fever. Laboratory findings showed strongly increased rheumatoid factor [158 IU/mL (normal range 0-15 IU/mL)] and normal leucocyte count [8.Histopathological examination of vesicular lesions showed a subepidermal blister filled with neutrophils and an extensive neutrophilic infiltrate in the upper dermis without vasculitis (Fig. 2). Direct immunofluorescence (DIF) studies of a perilesional skin biopsy revealed no deposits of C3, IgG, IgA, IgM or fibrinogen.What is your diagnosis? (a) (b) (c) (d) Figure 1 (a,b) Erythematous patch at site of healed bullae on the palms; (c) localized vesicles, papules and erosions with crust were seen on both soles; (d) a biopsy taken from the vesicle and direct immunofluorescence performed on the perilesional area on the lower leg.