Dermatology Case Question: May

Figure 1: Cutaneous eruption located on the sole of the foot.

The Case

A 60-year-old man with a history of seropositive rheumatoid arthritis (RA) presents with a new-onset, somewhat painful, cutaneous eruption located on the palms and soles (see Figure 1). He feels well otherwise and has no other systemic complaints. On exam, he is afebrile and his joint exam is unchanged from his last visit two months earlier. Medications include methotrexate 15 mg orally once weekly (for two years) and adalimumab 40 mg subcutaneous injection every two weeks (beginning two months ago).

What is your diagnosis?

1. Pustular ‘Id’ reaction
2. Keratoderma blennorrhagicum
3. Tumor necrosis factor–α-induced palmo plantar pustular psoriasis
4. Dyshidrotic eczema
5. Impetigo

Dr. Femia is a fellow in the dermatology–rheumatology fellowship at Brigham and Women’s Hospital in Boston. She is a diplomat of the American Board of Dermatology.

Dr. Merola is an instructor in the department of dermatology at Harvard Medical School and a fellow in the rheumatology division at Brigham and Women’s Hospital, both in Boston. He is the assistant program director for the combined medicine–dermatology training program and a diplomat of the American Board of Dermatology and the American Board of Internal Medicine.