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Case 11

15-year-old girl with painful doughy swelling of the fingers and toes

Since last weekend—that is for 3 days.

Reasonable question, as these lesions tend to appear over a few days and then heal spontaneously over days to weeks.

Yes, they itch and are tender to touch.

Good question. This dermatosis can be pruritic, painful or burning.

The pain gets worse when I come into a warm place from outdoors.

Good question. This dermatosis is caused by exposure to cold and becomes more symptomatic with changing of environmental temperature.

No, nothing special. I always go horseback riding and this time we were out for a long time, even though it was quite cold.

Important question, as exposure to cold is an important part of the process.

No, this is the first time.

Good question, as these lesions may recur over years.

No, none that I know of.

Always a good question, especially in the differential diagnostic process.

Choose the right efflorescences:

Correct. The lesions are puffy red-blue nodules.

Incorrect. The lesions are larger than papules.

Incorrect. No scaling is seen.

Incorrect. A macule is flat; these lesions are raised and palpable.

Choose the right diagnosis:

Incorrect, but an important consideration. The lupus pernio variant of sarcoidosis may appear similar.

Incorrect. Chilblain lupus appears similar but the history of cold exposure is not present.

Incorrect. Rosacea is a facial dermatosis of adults.

Correct. Pernio develops after long exposure to cold, especially on the face, hands and thighs (of horseback riders). It worsens with changing temperatures and is often pruritic, tender or burning.

Incorrect. Allergic contact dermatitis features papules, vesicles, scales and often crusts.

Choose the right therapy(ies):

Correct. Topical anti-inflammatory agents may provide some relief.

Incorrect. These agents are not appropriate as there is no evidence for infection.

Correct. Production from cold and moisture is important. Sometimes vascular training with exposure to varying temperatures (such as sauna) may help.

Correct. Anything which stimulates the circulation may help. Some especially sensitive patients may benefit from calcium channel blockers such as nifedipine.

Wrong! Protection from cold is needed, not deliberate exposure.

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