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A 32-year-old Nigerian woman presented with dull pain, pruritus, and discoloration of the dorsal aspect of both feet for 18 months. Her medical history included a red blood cell transfusion as a child and 2 uncomplicated pregnancies.
The lesions started as small papules on the dorsal right great toe and left third toe that gradually spread across the dorsum of her feet over the following 12 months. An over-the-counter antifungal ointment was unhelpful. Her primary care physician completed a biopsy, diagnosed verruca plantaris, and prescribed topical salicylic acid twice daily for 4 weeks. The lesions did not improve, and her foot pain worsened. Subsequent treatment with topical liquid nitrogen cryotherapy was ineffective.
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Hepatitis C–induced necrolytic acral erythema (NAE)
D. Prescribe oral zinc therapy
The keys to the correct diagnosis in this case were the childhood history of a red blood cell transfusion associated with acquisition of HCV, the dorsal distribution of lesions, and intraepidermal necrosis on the biopsy.1,2 In patients with hepatitis C–induced NAE, the combination of hypertrophic verrucous plaques and microscopic findings of psoriasiform hyperplasia commonly result in the misdiagnosis of psoriasis, eczematous dermatitis, or hypertrophic lichen planus.3 Because the punch biopsy provided diagnostic information, an incisional biopsy (choice A) was not required. Additionally, the case offers no clinical indications for the use of antibiotics (choice B) or further imaging (choice C).
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Corresponding Author: Gordon T. Moffat, MD, Department of Medicine, State University of New York Downstate Health Sciences University, 450 Clarkson Ave, MSC 50, Brooklyn, NY 11203 (Gordon.firstname.lastname@example.org).
Published Online: January 15, 2021. doi:10.1001/jama.2020.16053
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank Jessica Maloh, BSc, Canadian College of Naturopathic Medicine, for contributing to this article. Ms Maloh did not receive any compensation for her contributions. We thank the patient for providing permission to share her information.
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