As Problem Spreads, Man Seeks Help

For several months, a 30-year-old man has had an asymptomatic rash on his legs. The lesions first appeared on his lower legs and ankles; over the subsequent months, they have spread upward. Now, the rash reaches to just below his knees. During this time, he has had two bouts of strep throat, both adequately treated. He denies any other skin problems and has no relevant family history. The patient denies alcohol or drug abuse and is not taking any prescription medications. Prior to referral to dermatology, he was seen in two urgent care clinics; at one, he received a diagnosis of fungal infection and at the other, of “vitamin deficiency.” He was given a month-long course of terbinafine (250 mg/d) that produced no change in his rash. He achieved the same (non)result from an increased intake of vitamins. Examination reveals annular reddish brown macules, measuring 1 to 3 cm, sparsely distributed from the knees to just above the ankles on both legs. The lesions are a bit more densely arrayed on the anterior legs. There is no palpable component to any of them and no discernable surface scale. Digital pressure fails to blanch the lesions. The hairs and follicles on the patient’s legs appear normal. There are no notable skin changes elsewhere, and the patient is alert, oriented, and in no distress.