A 70-year-old Thai female with a significant medical history presented with acute chest pain that had persisted for 4 hours. Upon examination and evaluation, she was diagnosed with hypertensive emergency complicated by heart failure, necessitating immediate treatment with intravenous diuretics.

In addition to her acute condition, the patient had been experiencing a pruritic skin rash on both legs for the past 4 months. The rash had progressively worsened over this period.

The patient’s medical background includes hypertension, dyslipidemia, diabetes mellitus, and chronic kidney disease stage 5.

Dermatologic Examination: Multiple discrete and some linear, well-defined erythematous to brownish papules with central keratotic crusts and an erythematous halo on both legs.

Questions:

1. What is the provisional diagnosis of this skin condition?

2. Which of her underlying diseases is related to this skin condition?

โดย อาจารย์ ร.อ.ยุทธรัตน์ สุวรรณชาติกุล แพทย์เฉพาะทางสาขาตจวิทยา กองตรวจโรคผู้ป่วยนอก รพ.ภูมิพลอดุลยเดช กรมแพทย์ทหารอากาศ

ANSWERs

1. Provisional diagnosis  Acquired perforating dermatosis

• A group of conditions characterized by the transepidermal elimination of collagen, elastic fibers, or necrotic connective tissue in the dermis.
• A clue to the diagnosis is the presence of a central keratotic core, which is sometimes physically removed by the patient.
• Commonly associated with diabetes mellitus and/or the pruritus associated with advanced chronic kidney disease (stages 4–5), and rarely liver disease. It typically affects the lower legs in adults (notably 10% of dialysis patients) but can also present as generalized or widely scattered papules, nodules, and show the Koebner phenomenon.
• The differential diagnosis should consider conditions such as prurigo simplex, prurigo nodularis, folliculitis, psoriasis, lichen planus, and verruca vulgaris.
• Reported treatments, often derived from small case series, include topical corticosteroids, topical retinoids, and in cases of end-stage chronic kidney disease, transplantation may improve the condition. Narrowband UVB phototherapy is considered the most effective treatment.

2. The underlying diseases related to the skin condition included 

• Diabetes mellitus
• Chronic kidney disease stage 5 

โดย อาจารย์ ร.อ.ยุทธรัตน์ สุวรรณชาติกุล แพทย์เฉพาะทางสาขาตจวิทยา กองตรวจโรคผู้ป่วยนอก รพ.ภูมิพลอดุลยเดช กรมแพทย์ทหารอากาศ