Violaceous papules and nodules overlying bilateral dorsal hands

BackgroundA 57-year-old man with no medical or trauma history presents with well-circumscribed violaceous papules and nodules on dorsal hands bilaterally for several years without itching, bleeding, or burning (Fig 1). Shave biopsy of the lesion demonstrated an ulcerated lesion with a neutrophilic infiltrate, some exhibiting karyorrhexis (Fig 2). There were increased spaces between the dermal collagen representing collagen degeneration with an increase in mucin deposition, histiocytes, lymphocytes, and neutrophils (Fig 3). Comprehensive metabolic panel, complete blood count, complement, sedimentation rate, rheumatoid factor, serum protein electrophoresis, myeloperoxidase antibodies, proteinase 3 antibodies, antinuclear antibodies, Lyme antibodies, hepatitis, and HIV testing were all negative.Fig 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 3View Large Image Figure ViewerDownload Hi-res image Download (PPT)Question 1: What is the diagnosis?A.Granuloma annulare (GA)B.SarcoidosisC.Interstitial granulomatous dermatitisD.Rheumatoid nodules (RNs)E.Palisading neutrophilic granulomatous dermatitis (PNGD)Answer:A.GA – Incorrect. A palisading or interstitial patchy infiltrates concentrated in the superficial and mid-dermis with focal mucin deposition would be seen in GA.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsevier Health Sciences, 2017: 409-439Google Scholar It is differentiated from PNGD by a relative absence of neutrophils and leukocytoclasis.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsevier Health Sciences, 2017: 409-439Google ScholarB.Sarcoidosis – Incorrect. This can present with red-brown to violaceous papules and plaques most commonly on the face, however can have varying presentations. Histology shows noncaseating epithelioid granulomas with a sparse or absent surrounding lymphocytic inflammation.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsevier Health Sciences, 2017: 409-439Google ScholarC.Interstitial granulomatous dermatitis – Incorrect. This presents with annular plaques or linear cords which appear on the trunk, axillae, and medial thighs in patients with rheumatoid arthritis or seronegative arthritis.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsevier Health Sciences, 2017: 409-439Google Scholar Histology reveals rosettes of palisading histiocytes which besiege miniscule foci of degenerated collagen with variable presence of neutrophils, absence of dermal mucin, and without evidence of vasculitis.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsevier Health Sciences, 2017: 409-439Google ScholarD.RNs – Incorrect. These are firm, semi-mobile papulonodules present mostly over extensor surfaces.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsevier Health Sciences, 2017: 409-439Google Scholar RNs exhibit infiltrate in the deep dermis and subcutis. A palisaded layer of histiocytes and granulation tissue surrounding a central zone of eosinophilic fibrin composes RNs. An interstitial neutrophilic infiltrate can be observed in early lesions. Comparatively, neutrophils are more prominent in PNGD and are present regardless of timing.E.PNGD – Correct. PNGD is a neutrophilic dermatosis that presents as skin-colored to erythematous umbilicated papules symmetrically distributed over the extensor surfaces.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsevier Health Sciences, 2017: 409-439Google Scholar The histopathological findings include small vessel vasculitis with prominent neutrophils, leukocytoclasis, or palisading granulomas.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsevier Health Sciences, 2017: 409-439Google Scholar There may be associated basophilic degenerated collagen.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsevier Health Sciences, 2017: 409-439Google ScholarQuestion 2: Which of the following is not associated with the diagnosis?A.Systemic lupus erythematosusB.Wegener granulomatosisC.Rheumatoid arthritis (RA)D.Fungal infectionE.MalignancyAnswer:A.Systemic lupus erythematosus – Incorrect. PNGD can be associated with systemic lupus erythematosus, a systemic autoimmune condition that has varying presentations from a cutaneous lesion to renal failure. PNGD has been shown to be associated with autoimmune conditions such as lupus likely due to the fact that PNGD develops as a result of perivascular immune-complex deposition triggered by systemic inflammatory pathologies.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsevier Health Sciences, 2017: 409-439Google ScholarB.Wegener granulomatosis – Incorrect. PNGD can be associated with Wegener granulomatosis, a disorder characterized as granulomatous inflammation of the respiratory tracts, necrotizing small vessel vasculitis, and pauci-immune glomerulonephritis.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsevier Health Sciences, 2017: 409-439Google Scholar The systemic inflammatory response can trigger the development of PNGD lesions.C.RA – Incorrect. PNGD can be associated with RA, as RA is a systemic inflammatory autoimmune condition which can cause complex deposition necessary to initiate PNGD pathology.D.Fungal infection – Correct. PNGD is not associated with fungal infection. Infections such as chronic hepatitis C and Lyme disease have been reported in association with PNGD, however fungal infections specifically have not.2Shenk M.E.R. Ken K.M. Braudis K. Fernandez K.H. Palisaded neutrophilic and granulomatous dermatitis associated with ledipasvir/sofosbuvir.JAAD Case Rep. 2018; 4: 808-810https://doi.org/10.1016/j.jdcr.2018.06.025Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar,3Pirowska M. Obtułowicz A. Dyduch G. Lipko-Godlewska S. Wojas-Pelc A. Palisaded neutrophilic and granulomatous dermatitis - cutaneous manifestation of Lyme disease or connected with CTD? Case report.Ann Agric Environ Med. 2016; 23: 384-386https://doi.org/10.5604/12321966.1203913Crossref PubMed Scopus (1) Google Scholar Other infections that have been associated with PNGD include Streptococcus, HIV, Epstein-Barr virus, and parvovirus.4Kalen J.E. Shokeen D. Ramos-Caro F. Motaparthi K. Palisaded neutrophilic granulomatous dermatitis: spectrum of histologic findings in a single patient.JAAD Case Rep. 2017; 3: 425-428https://doi.org/10.1016/j.jdcr.2017.06.010Abstract Full Text Full Text PDF PubMed Scopus (15) Google ScholarE.Malignancy – Incorrect. PNGD has been associated with lymphoproliferative malignancies such as chronic myelomonocytic leukemia, non-Hodgkin lymphoma, and Hodgkin lymphoma.5Zabihi-Pour D. Bahrani B. Assaad D. Yeung J. Palisaded neutrophilic and granulomatous dermatitis following a long-standing monoclonal gammopathy: a case report.SAGE Open Med Case Rep. 2021; 9 (2050313X20979560)https://doi.org/10.1177/2050313X20979560PubMed Google Scholar PNGD has been reported to develop prior to onset of these malignancies. Therefore, PNGD lesions may be an early indicator for a slew of pathologies. Because of these rare but possible associations, underlying malignancy in patients with PNGD should be ruled out, especially in those with constitutional symptoms without overt inflammatory etiology.Question 3: Which of the following is not a treatment option?A.Treatment of underlying diseaseB.Topical steroidsC.DapsoneD.HydroxychloroquineE.Ledipasvir/sofosbuvirAnswer:A.Treatment of underlying disease – Incorrect. Treating the underlying disease has been shown to resolve the existing lesions and prevent recurrences.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsevier Health Sciences, 2017: 409-439Google ScholarB.Topical steroids – Incorrect. There is no one targeted therapy for PNGD. However, there have been reports showing improvement with the use of potent corticosteroids either topically or via intralesional application.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsevier Health Sciences, 2017: 409-439Google ScholarC.Dapsone – Incorrect. Dapsone has been shown to improve the lesions in a few case reports.4Kalen J.E. Shokeen D. Ramos-Caro F. Motaparthi K. Palisaded neutrophilic granulomatous dermatitis: spectrum of histologic findings in a single patient.JAAD Case Rep. 2017; 3: 425-428https://doi.org/10.1016/j.jdcr.2017.06.010Abstract Full Text Full Text PDF PubMed Scopus (15) Google ScholarD.Hydroxychloroquine – Incorrect. Hydroxychloroquine has also been shown to be an effective treatment for PNGD in some cases.4Kalen J.E. Shokeen D. Ramos-Caro F. Motaparthi K. Palisaded neutrophilic granulomatous dermatitis: spectrum of histologic findings in a single patient.JAAD Case Rep. 2017; 3: 425-428https://doi.org/10.1016/j.jdcr.2017.06.010Abstract Full Text Full Text PDF PubMed Scopus (15) Google ScholarE.Ledipasvir/sofosbuvir – Correct. Ledipasvir/sofosbuvir is not a treatment option for PNGD. It is an oral, direct-acting antiviral medication used to treat chronic hepatitis C virus infection which has actually been associated with the development of PNGD.2Shenk M.E.R. Ken K.M. Braudis K. Fernandez K.H. Palisaded neutrophilic and granulomatous dermatitis associated with ledipasvir/sofosbuvir.JAAD Case Rep. 2018; 4: 808-810https://doi.org/10.1016/j.jdcr.2018.06.025Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar BackgroundA 57-year-old man with no medical or trauma history presents with well-circumscribed violaceous papules and nodules on dorsal hands bilaterally for several years without itching, bleeding, or burning (Fig 1). Shave biopsy of the lesion demonstrated an ulcerated lesion with a neutrophilic infiltrate, some exhibiting karyorrhexis (Fig 2). There were increased spaces between the dermal collagen representing collagen degeneration with an increase in mucin deposition, histiocytes, lymphocytes, and neutrophils (Fig 3). Comprehensive metabolic panel, complete blood count, complement, sedimentation rate, rheumatoid factor, serum protein electrophoresis, myeloperoxidase antibodies, proteinase 3 antibodies, antinuclear antibodies, Lyme antibodies, hepatitis, and HIV testing were all negative.Fig 3View Large Image Figure ViewerDownload Hi-res image Download (PPT)Question 1: What is the diagnosis?A.Granuloma annulare (GA)B.SarcoidosisC.Interstitial granulomatous dermatitisD.Rheumatoid nodules (RNs)E.Palisading neutrophilic granulomatous dermatitis (PNGD)Answer:A.GA – Incorrect. A palisading or interstitial patchy infiltrates concentrated in the superficial and mid-dermis with focal mucin deposition would be seen in GA.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsevier Health Sciences, 2017: 409-439Google Scholar It is differentiated from PNGD by a relative absence of neutrophils and leukocytoclasis.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsevier Health Sciences, 2017: 409-439Google ScholarB.Sarcoidosis – Incorrect. This can present with red-brown to violaceous papules and plaques most commonly on the face, however can have varying presentations. Histology shows noncaseating epithelioid granulomas with a sparse or absent surrounding lymphocytic inflammation.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsevier Health Sciences, 2017: 409-439Google ScholarC.Interstitial granulomatous dermatitis – Incorrect. This presents with annular plaques or linear cords which appear on the trunk, axillae, and medial thighs in patients with rheumatoid arthritis or seronegative arthritis.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsevier Health Sciences, 2017: 409-439Google Scholar Histology reveals rosettes of palisading histiocytes which besiege miniscule foci of degenerated collagen with variable presence of neutrophils, absence of dermal mucin, and without evidence of vasculitis.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsevier Health Sciences, 2017: 409-439Google ScholarD.RNs – Incorrect. These are firm, semi-mobile papulonodules present mostly over extensor surfaces.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsevier Health Sciences, 2017: 409-439Google Scholar RNs exhibit infiltrate in the deep dermis and subcutis. A palisaded layer of histiocytes and granulation tissue surrounding a central zone of eosinophilic fibrin composes RNs. An interstitial neutrophilic infiltrate can be observed in early lesions. Comparatively, neutrophils are more prominent in PNGD and are present regardless of timing.E.PNGD – Correct. PNGD is a neutrophilic dermatosis that presents as skin-colored to erythematous umbilicated papules symmetrically distributed over the extensor surfaces.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsevier Health Sciences, 2017: 409-439Google Scholar The histopathological findings include small vessel vasculitis with prominent neutrophils, leukocytoclasis, or palisading granulomas.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsevier Health Sciences, 2017: 409-439Google Scholar There may be associated basophilic degenerated collagen.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsevier Health Sciences, 2017: 409-439Google ScholarQuestion 2: Which of the following is not associated with the diagnosis?A.Systemic lupus erythematosusB.Wegener granulomatosisC.Rheumatoid arthritis (RA)D.Fungal infectionE.MalignancyAnswer:A.Systemic lupus erythematosus – Incorrect. PNGD can be associated with systemic lupus erythematosus, a systemic autoimmune condition that has varying presentations from a cutaneous lesion to renal failure. PNGD has been shown to be associated with autoimmune conditions such as lupus likely due to the fact that PNGD develops as a result of perivascular immune-complex deposition triggered by systemic inflammatory pathologies.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsevier Health Sciences, 2017: 409-439Google ScholarB.Wegener granulomatosis – Incorrect. PNGD can be associated with Wegener granulomatosis, a disorder characterized as granulomatous inflammation of the respiratory tracts, necrotizing small vessel vasculitis, and pauci-immune glomerulonephritis.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsevier Health Sciences, 2017: 409-439Google Scholar The systemic inflammatory response can trigger the development of PNGD lesions.C.RA – Incorrect. PNGD can be associated with RA, as RA is a systemic inflammatory autoimmune condition which can cause complex deposition necessary to initiate PNGD pathology.D.Fungal infection – Correct. PNGD is not associated with fungal infection. Infections such as chronic hepatitis C and Lyme disease have been reported in association with PNGD, however fungal infections specifically have not.2Shenk M.E.R. Ken K.M. Braudis K. Fernandez K.H. Palisaded neutrophilic and granulomatous dermatitis associated with ledipasvir/sofosbuvir.JAAD Case Rep. 2018; 4: 808-810https://doi.org/10.1016/j.jdcr.2018.06.025Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar,3Pirowska M. Obtułowicz A. Dyduch G. Lipko-Godlewska S. Wojas-Pelc A. Palisaded neutrophilic and granulomatous dermatitis - cutaneous manifestation of Lyme disease or connected with CTD? Case report.Ann Agric Environ Med. 2016; 23: 384-386https://doi.org/10.5604/12321966.1203913Crossref PubMed Scopus (1) Google Scholar Other infections that have been associated with PNGD include Streptococcus, HIV, Epstein-Barr virus, and parvovirus.4Kalen J.E. Shokeen D. Ramos-Caro F. Motaparthi K. Palisaded neutrophilic granulomatous dermatitis: spectrum of histologic findings in a single patient.JAAD Case Rep. 2017; 3: 425-428https://doi.org/10.1016/j.jdcr.2017.06.010Abstract Full Text Full Text PDF PubMed Scopus (15) Google ScholarE.Malignancy – Incorrect. PNGD has been associated with lymphoproliferative malignancies such as chronic myelomonocytic leukemia, non-Hodgkin lymphoma, and Hodgkin lymphoma.5Zabihi-Pour D. Bahrani B. Assaad D. Yeung J. Palisaded neutrophilic and granulomatous dermatitis following a long-standing monoclonal gammopathy: a case report.SAGE Open Med Case Rep. 2021; 9 (2050313X20979560)https://doi.org/10.1177/2050313X20979560PubMed Google Scholar PNGD has been reported to develop prior to onset of these malignancies. Therefore, PNGD lesions may be an early indicator for a slew of pathologies. Because of these rare but possible associations, underlying malignancy in patients with PNGD should be ruled out, especially in those with constitutional symptoms without overt inflammatory etiology.Question 3: Which of the following is not a treatment option?A.Treatment of underlying diseaseB.Topical steroidsC.DapsoneD.HydroxychloroquineE.Ledipasvir/sofosbuvirAnswer:A.Treatment of underlying disease – Incorrect. Treating the underlying disease has been shown to resolve the existing lesions and prevent recurrences.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsevier Health Sciences, 2017: 409-439Google ScholarB.Topical steroids – Incorrect. There is no one targeted therapy for PNGD. However, there have been reports showing improvement with the use of potent corticosteroids either topically or via intralesional application.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsevier Health Sciences, 2017: 409-439Google ScholarC.Dapsone – Incorrect. Dapsone has been shown to improve the lesions in a few case reports.4Kalen J.E. Shokeen D. Ramos-Caro F. Motaparthi K. Palisaded neutrophilic granulomatous dermatitis: spectrum of histologic findings in a single patient.JAAD Case Rep. 2017; 3: 425-428https://doi.org/10.1016/j.jdcr.2017.06.010Abstract Full Text Full Text PDF PubMed Scopus (15) Google ScholarD.Hydroxychloroquine – Incorrect. Hydroxychloroquine has also been shown to be an effective treatment for PNGD in some cases.4Kalen J.E. Shokeen D. Ramos-Caro F. Motaparthi K. Palisaded neutrophilic granulomatous dermatitis: spectrum of histologic findings in a single patient.JAAD Case Rep. 2017; 3: 425-428https://doi.org/10.1016/j.jdcr.2017.06.010Abstract Full Text Full Text PDF PubMed Scopus (15) Google ScholarE.Ledipasvir/sofosbuvir – Correct. Ledipasvir/sofosbuvir is not a treatment option for PNGD. It is an oral, direct-acting antiviral medication used to treat chronic hepatitis C virus infection which has actually been associated with the development of PNGD.2Shenk M.E.R. Ken K.M. Braudis K. Fernandez K.H. Palisaded neutrophilic and granulomatous dermatitis associated with ledipasvir/sofosbuvir.JAAD Case Rep. 2018; 4: 808-810https://doi.org/10.1016/j.jdcr.2018.06.025Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar A 57-year-old man with no medical or trauma history presents with well-circumscribed violaceous papules and nodules on dorsal hands bilaterally for several years without itching, bleeding, or burning (Fig 1). Shave biopsy of the lesion demonstrated an ulcerated lesion with a neutrophilic infiltrate, some exhibiting karyorrhexis (Fig 2). There were increased spaces between the dermal collagen representing collagen degeneration with an increase in mucin deposition, histiocytes, lymphocytes, and neutrophils (Fig 3). Comprehensive metabolic panel, complete blood count, complement, sedimentation rate, rheumatoid factor, serum protein electrophoresis, myeloperoxidase antibodies, proteinase 3 antibodies, antinuclear antibodies, Lyme antibodies, hepatitis, and HIV testing were all negative. Question 1: What is the diagnosis?A.Granuloma annulare (GA)B.SarcoidosisC.Interstitial granulomatous dermatitisD.Rheumatoid nodules (RNs)E.Palisading neutrophilic granulomatous dermatitis (PNGD) Answer:A.GA – Incorrect. A palisading or interstitial patchy infiltrates concentrated in the superficial and mid-dermis with focal mucin deposition would be seen in GA.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsevier Health Sciences, 2017: 409-439Google Scholar It is differentiated from PNGD by a relative absence of neutrophils and leukocytoclasis.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsevier Health Sciences, 2017: 409-439Google ScholarB.Sarcoidosis – Incorrect. This can present with red-brown to violaceous papules and plaques most commonly on the face, however can have varying presentations. Histology shows noncaseating epithelioid granulomas with a sparse or absent surrounding lymphocytic inflammation.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsevier Health Sciences, 2017: 409-439Google ScholarC.Interstitial granulomatous dermatitis – Incorrect. This presents with annular plaques or linear cords which appear on the trunk, axillae, and medial thighs in patients with rheumatoid arthritis or seronegative arthritis.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsevier Health Sciences, 2017: 409-439Google Scholar Histology reveals rosettes of palisading histiocytes which besiege miniscule foci of degenerated collagen with variable presence of neutrophils, absence of dermal mucin, and without evidence of vasculitis.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsevier Health Sciences, 2017: 409-439Google ScholarD.RNs – Incorrect. These are firm, semi-mobile papulonodules present mostly over extensor surfaces.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsevier Health Sciences, 2017: 409-439Google Scholar RNs exhibit infiltrate in the deep dermis and subcutis. A palisaded layer of histiocytes and granulation tissue surrounding a central zone of eosinophilic fibrin composes RNs. An interstitial neutrophilic infiltrate can be observed in early lesions. Comparatively, neutrophils are more prominent in PNGD and are present regardless of timing.E.PNGD – Correct. PNGD is a neutrophilic dermatosis that presents as skin-colored to erythematous umbilicated papules symmetrically distributed over the extensor surfaces.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsevier Health Sciences, 2017: 409-439Google Scholar The histopathological findings include small vessel vasculitis with prominent neutrophils, leukocytoclasis, or palisading granulomas.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsevier Health Sciences, 2017: 409-439Google Scholar There may be associated basophilic degenerated collagen.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsevier Health Sciences, 2017: 409-439Google Scholar Question 2: Which of the following is not associated with the diagnosis?A.Systemic lupus erythematosusB.Wegener granulomatosisC.Rheumatoid arthritis (RA)D.Fungal infectionE.Malignancy Answer:A.Systemic lupus erythematosus – Incorrect. PNGD can be associated with systemic lupus erythematosus, a systemic autoimmune condition that has varying presentations from a cutaneous lesion to renal failure. PNGD has been shown to be associated with autoimmune conditions such as lupus likely due to the fact that PNGD develops as a result of perivascular immune-complex deposition triggered by systemic inflammatory pathologies.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsevier Health Sciences, 2017: 409-439Google ScholarB.Wegener granulomatosis – Incorrect. PNGD can be associated with Wegener granulomatosis, a disorder characterized as granulomatous inflammation of the respiratory tracts, necrotizing small vessel vasculitis, and pauci-immune glomerulonephritis.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsevier Health Sciences, 2017: 409-439Google Scholar The systemic inflammatory response can trigger the development of PNGD lesions.C.RA – Incorrect. PNGD can be associated with RA, as RA is a systemic inflammatory autoimmune condition which can cause complex deposition necessary to initiate PNGD pathology.D.Fungal infection – Correct. PNGD is not associated with fungal infection. Infections such as chronic hepatitis C and Lyme disease have been reported in association with PNGD, however fungal infections specifically have not.2Shenk M.E.R. Ken K.M. Braudis K. Fernandez K.H. Palisaded neutrophilic and granulomatous dermatitis associated with ledipasvir/sofosbuvir.JAAD Case Rep. 2018; 4: 808-810https://doi.org/10.1016/j.jdcr.2018.06.025Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar,3Pirowska M. Obtułowicz A. Dyduch G. Lipko-Godlewska S. Wojas-Pelc A. Palisaded neutrophilic and granulomatous dermatitis - cutaneous manifestation of Lyme disease or connected with CTD? Case report.Ann Agric Environ Med. 2016; 23: 384-386https://doi.org/10.5604/12321966.1203913Crossref PubMed Scopus (1) Google Scholar Other infections that have been associated with PNGD include Streptococcus, HIV, Epstein-Barr virus, and parvovirus.4Kalen J.E. Shokeen D. Ramos-Caro F. Motaparthi K. Palisaded neutrophilic granulomatous dermatitis: spectrum of histologic findings in a single patient.JAAD Case Rep. 2017; 3: 425-428https://doi.org/10.1016/j.jdcr.2017.06.010Abstract Full Text Full Text PDF PubMed Scopus (15) Google ScholarE.Malignancy – Incorrect. PNGD has been associated with lymphoproliferative malignancies such as chronic myelomonocytic leukemia, non-Hodgkin lymphoma, and Hodgkin lymphoma.5Zabihi-Pour D. Bahrani B. Assaad D. Yeung J. Palisaded neutrophilic and granulomatous dermatitis following a long-standing monoclonal gammopathy: a case report.SAGE Open Med Case Rep. 2021; 9 (2050313X20979560)https://doi.org/10.1177/2050313X20979560PubMed Google Scholar PNGD has been reported to develop prior to onset of these malignancies. Therefore, PNGD lesions may be an early indicator for a slew of pathologies. Because of these rare but possible associations, underlying malignancy in patients with PNGD should be ruled out, especially in those with constitutional symptoms without overt inflammatory etiology. Question 3: Which of the following is not a treatment option?A.Treatment of underlying diseaseB.Topical steroidsC.DapsoneD.HydroxychloroquineE.Ledipasvir/sofosbuvir Answer:A.Treatment of underlying disease – Incorrect. Treating the underlying disease has been shown to resolve the existing lesions and prevent recurrences.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsevier Health Sciences, 2017: 409-439Google ScholarB.Topical steroids – Incorrect. There is no one targeted therapy for PNGD. However, there have been reports showing improvement with the use of potent corticosteroids either topically or via intralesional application.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsevier Health Sciences, 2017: 409-439Google ScholarC.Dapsone – Incorrect. Dapsone has been shown to improve the lesions in a few case reports.4Kalen J.E. Shokeen D. Ramos-Caro F. Motaparthi K. Palisaded neutrophilic granulomatous dermatitis: spectrum of histologic findings in a single patient.JAAD Case Rep. 2017; 3: 425-428https://doi.org/10.1016/j.jdcr.2017.06.010Abstract Full Text Full Text PDF PubMed Scopus (15) Google ScholarD.Hydroxychloroquine – Incorrect. Hydroxychloroquine has also been shown to be an effective treatment for PNGD in some cases.4Kalen J.E. Shokeen D. Ramos-Caro F. Motaparthi K. Palisaded neutrophilic granulomatous dermatitis: spectrum of histologic findings in a single patient.JAAD Case Rep. 2017; 3: 425-428https://doi.org/10.1016/j.jdcr.2017.06.010Abstract Full Text Full Text PDF PubMed Scopus (15) Google ScholarE.Ledipasvir/sofosbuvir – Correct. Ledipasvir/sofosbuvir is not a treatment option for PNGD. It is an oral, direct-acting antiviral medication used to treat chronic hepatitis C virus infection which has actually been associated with the development of PNGD.2Shenk M.E.R. Ken K.M. Braudis K. Fernandez K.H. Palisaded neutrophilic and granulomatous dermatitis associated with ledipasvir/sofosbuvir.JAAD Case Rep. 2018; 4: 808-810https://doi.org/10.1016/j.jdcr.2018.06.025Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar None disclosed.