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Nonhealing Genital Ulcers as Clue to a Multisystem Disease

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A female patient in her late 40s presented with a 3-year history of nonhealing ulcers in her groin and axillae. These lesions started as itchy, weepy, reddish papules and plaques, which gradually progressed to form ulcers and were associated with pain and pus discharge. They did not heal completely after multiple courses of topical as well as systemic antibiotics, antifungals, and steroids. She frequently experienced scaling and greasiness on her scalp, which was treated with shampoos and topical steroids. She also complained of polyuria and polydipsia for the past 4 years.

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A female patient in her late 40s presented with a 3-year history of nonhealing ulcers in her groin and axillae. These lesions started as itchy, weepy, reddish papules and plaques, which gradually progressed to form ulcers and were associated with pain and pus discharge. They did not heal completely after multiple courses of topical as well as systemic antibiotics, antifungals, and steroids. She frequently experienced scaling and greasiness on her scalp, which was treated with shampoos and topical steroids. She also complained of polyuria and polydipsia for the past 4 years.

General examination revealed multiple mobile, firm, nonmatted, and nontender lymph nodes in cervical and inguinal region. On systemic examination, hepatomegaly (2 cm below the right costal margin) was seen. There was also bilateral enlargement of the parotid area, which was tender on palpation. Cutaneous examination revealed yellowish greasy scales on the scalp, suggestive of seborrheic dermatitis. Erythematous edematous papules were present over the retroauricular areas and the inframammary folds (Figure, A). On examination of external genitalia, deep ulcers were observed in the bilateral inguinal folds, resembling knife-cut ulcers (Figure, B). Similar lesions were present over the junction of labia majora and labia minora and were associated with yellowish pus discharge. A 3.5-mm punch biopsy specimen was obtained for histopathological examination from the edge of an ulcer on one of the groin folds (Figure, C and D).

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Article Information

Corresponding Author: Keshavamurthy Vinay, MD, DNB, Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India (vinay.keshavmurthy@gmail.com).

Published Online: January 11, 2023. doi:10.1001/jamadermatol.2022.5863

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
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Mu  EW , Khurram  NA , Pei  Z ,  et al.  55-year-old man with ulcers in inguinal fold and intergluteal cleft found to have systemic Langerhans cell histiocytosis.   JAAD Case Rep. 2018;4(8):837-840. doi:10.1016/j.jdcr.2018.05.016PubMedGoogle ScholarCrossref
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Singh  A , Prieto  VG , Czelusta  A , McClain  KL , Duvic  M .  Adult Langerhans cell histiocytosis limited to the skin.   Dermatology. 2003;207(2):157-161. doi:10.1159/000071786PubMedGoogle ScholarCrossref
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Kurtzman  DJB , Jones  T , Lian  F , Peng  LS .  Metastatic Crohn’s disease: a review and approach to therapy.   J Am Acad Dermatol. 2014;71(4):804-813. doi:10.1016/j.jaad.2014.04.002PubMedGoogle ScholarCrossref
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Nakamura  K , Tsunemi  Y , Kaneko  F , Alpsoy  E .  Mucocutaneous manifestations of Behçet’s disease.   Front Med (Lausanne). 2021;7:613432. doi:10.3389/fmed.2020.613432PubMedGoogle ScholarCrossref
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Charli-Joseph  Y , Saeb-Lima  M , Hernández-Salazar  A , Domínguez-Cherit  J .  Nasal-type extranodal natural killer/T-cell lymphoma presenting as genital ulcers.   J Am Acad Dermatol. 2012;67(4):e157-e159. doi:10.1016/j.jaad.2011.12.031PubMedGoogle ScholarCrossref
AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 credit toward the CME of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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