Verrucous Plaques on the Hands and Feet

Abstract

A 16-year-old Hispanic male subject with a history of juvenile rheumatoid arthritis (JRA) had developed verrucous plaques on his hands and feet 4 years prior to presentation. These lesions would come and go and were not pruritic or otherwise symptomatic. He had no other skin complaints. There was no family history of skin disease or current skin complaints. The patient was on etanercept 50 mg weekly, methotrexate 25 mg weekly, thalidomide, and celecoxib. He was seen by his rheumatologist and thought to have an unusual fungal infection because of a yellowish discoloration of his nails. He was then referred to dermatology for further biopsy and culture prior to starting antifungals.Physical examination revealed verrucous plaques over the dorsal joint spaces of both hands. There were also a few dystrophic nails, but without any subungual debris (Fig. 1). There were thick verrucous plaques on the medial aspects of both feet and multiple thickened and slightly yellow toe nails (Fig. 2). The remainder of the skin examination was normal. A biopsy from the left foot was obtained and sent for routine histopathology and cultures. A toenail clipping was sent for PAS staining.