45-Year-Old Man With Dermatitis and Weight Loss

A 45-year-old man complained of anorexia, nausea, vomiting, diarrhea, and malaise of 8 months’ duration. Five months after onset of these symptoms, a pruritic, burning skin eruption developed around both ankles. The skin lesions rapidly spread to involve the oral cavity and most of his body. During the 8-month period, he lost 27 kg of body weight. Because of the eruption, the patient was initially examined by a dermatologist, who prescribed methylprednisolone, minocycline hydrochloride, cyproheptadine hydrochloride, and triamcinolone ointment for presumed vasculitis or possible lupus erythematosus. Concurrently, an internist assessed the problem of considerable weight loss. Two months after the initial visit, the patient reported severe pruritus, swelling, and burning pain that extended from the upper thigh to the ankles and was told to take diphenhydramine hydrochloride and to apply crotamiton cream mixed with triamcinolone cream as needed. Of significance was the clinical history of a pruritic, scaling erythema that had involved his face, back, and neck 4 years previously, which had resolved spontaneously within 2 months.
The patient was first assessed at our institution 4 months after the eruption developed. He appeared ill, lethargic, and cachectic. Examination of the skin (Fig. 1) revealed a scaling, crusted, polycyclic dermatitis on the trunk and extremities, most pronounced at the ankles and in the anogenital region. He had central hyperpigmented clearing, peripheral urticarial papules, and early peripheral vesicles. Slightly denuded erythematous gingival mucosa was noted. Significant (3+ on a scale of 1 to 4) pitting edema was evident pretibially. No hepatosplenomegaly or lymphadenopathy was palpable.