A 45-year-old woman comes to the physician with "reddish spots" on her legs. She first noticed them 3 months ago and says that they are slowly spreading. Her medical problems include type 2 diabetes mellitus, acid reflux disease, hypertension, chronic constipation, and hypothyroidism. Her medications include metformin, levothyroxine, lisinopril, omeprazole, and as-needed senna.
Her temperature is 37.2 C (99 F) , blood pressure is 120/80 mm Hg, pulse is 78/min, and respirations are 12/min. Her body mass index is 27 kg/m². Several spots are seen in the pretibial region of each leg, as shown in the image below. The examination also shows clear lung fields, normal first and second heart sounds, and a 1/6 systolic murmur at the apex.

Which of the following is the most likely diagnosis?

Question

A 45-year-old woman comes to the physician with "reddish spots" on her legs. She first noticed them 3 months ago and says that they are slowly spreading. Her medical problems include type 2 diabetes mellitus, acid reflux disease, hypertension, chronic constipation, and hypothyroidism. Her medications include metformin, levothyroxine, lisinopril, omeprazole, and as-needed senna.
Her temperature is 37.2 C (99 F) , blood pressure is 120/80 mm Hg, pulse is 78/min, and respirations are 12/min. Her body mass index is 27 kg/m². Several spots are seen in the pretibial region of each leg, as shown in the image below. The examination also shows clear lung fields, normal first and second heart sounds, and a 1/6 systolic murmur at the apex.

Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

Necrobiosis lipoidica diabeticorum (NLD) is a skin condition frequently seen in diabetics, although it is occasionally seen in nondiabetics as well. Because the skin lesions may precede the onset of diabetes, patients with NLD should be screened for diabetes. The lesions typically occur in the pretibial areas, starting as erythematous papules that later evolve into annular lesions with a yellowish-brown hue, dilated blood vessels, and central epidermal atrophy. Patients are usually asymptomatic but can develop pain, pruritus, or dysesthesia. Histological examination showing characteristic interstitial granulomatous dermatitis confirms the diagnosis. NLD lesions may occasionally ulcerate. In the absence of ulceration, treatment with high-potency topical or intralesional glucocorticoids can be attempted. (Choice A) Discoid lupus lesions are usually erythematous, scaly plaques with pigmentary changes, such as hyperpigmented rims, that are commonly seen on the face, scalp, and ears. They may also be present on the trunk and extremities. However, it is uncommon to find discoid lesions below the neck without lesions also being present above the neck. Discoid lupus (Choice B) Hypersensitivity reactions to drugs may manifest with a variety of skin lesions, including urticaria, morbilliform rash, erythroderma, or vasculitis/palpable purpura. Isolated, chronic, annular lesions would be uncommon. morbilliform rash vasculitis/palpable purpura (Choice D) Pretibial myxedema (thyroid dermopathy) presents as nonpitting edema and skin-colored or brawny, indurated plaques in the pretibial areas. It is almost always associated with other features of Graves' disease, especially ophthalmopathy. Pretibial myxedema (thyroid dermopathy) (Choice E) The most common skin manifestations of sarcoidosis are papules and plaques occurring in the face and neck, typically over the nose, nasolabial folds, and eyelids. The papules may be skin-colored, brownish, or hypopigmented. Patients with Lofgren syndrome (acute sarcoidosis and polyarthralgia) can have tender, erythematous, subcutaneous nodules in the anterior shin (erythema nodosum), usually associated with adenopathy and joint symptoms. erythema nodosum Educational objective: Necrobiosis lipoidica diabeticorum is a skin condition seen frequently in patients with diabetes. The lesions typically occur in the pretibial areas and manifest as annular lesions with a yellowish-brown hue, dilated blood vessels, and central epidermal atrophy. __________ References: Update on necrobiosis lipoidica: A review of etiology, diagnosis, and treatment options. (http://www.ncbi.nlm.nih.gov/pubmed/23969033) Dermatologic manifestation of diabetes. (http://www.ncbi.nlm.nih.gov/pubmed/21848812) Diagnosis of cutaneous sarcoidosis; clinical and the prognostic significance of skin lesions. (http://www.ncbi.nlm.nih.gov/pubmed/23521826)

A 45-Year-Old Woman Comes to the Physician with "Reddish Spots