Case Study: A 51-Year-Old Female with a Progressive Papular Rash and Arthralgia

Case at a Glance

A 51-year-old female with no significant past medical history presented with a two-month history of a progressive, occasionally pruritic rash on her hands and arms, accompanied by the new onset of bilateral wrist and hand stiffness. The patient expressed concern about a possible diagnosis of lupus.

Patient's Story

The patient is a 51-year-old female who reports being in her usual state of health until approximately two months prior to presentation. She first noticed a raised, hard rash developing on one hand. Over the following weeks, the rash spread to her other hand and began progressing up both arms. The lesions are sometimes itchy. Concurrently, she began experiencing significant stiffness and an aching sensation in both wrists and hands. She denies any recent changes to her diet, soaps, detergents, or other potential contact allergens. Concerned by the combination of skin and joint symptoms, she sought an opinion, specifically questioning if this could be a presentation of lupus.

Initial Assessment

On initial presentation (via telehealth consult), the patient described a papular, indurated (hard) rash distributed across the dorsum of her hands and extending proximally up her arms. She also reported associated arthralgia and stiffness in her wrists and small joints of the hands. She is not currently taking any medications and has no known medical conditions. The initial photographs submitted by the patient were close-up images of individual lesions, which were insufficient for a complete dermatological assessment.

The Diagnostic Journey

The primary challenge in the initial assessment was the lack of adequate visual information to characterize the rash fully. The consulting physician noted that the close-up images did not allow for an understanding of the overall distribution, pattern, and orientation of the lesions. To proceed with the differential diagnosis, the physician requested new photographs be taken from a further distance. This would allow for visualization of the entire rash on both arms, which is crucial for identifying patterns suggestive of specific conditions (e.g., symmetry, involvement of sun-exposed areas, relationship to joints).

Final Diagnosis

Awaiting further diagnostic workup. The differential diagnosis is broad and includes granuloma annulare, papular mucinosis, and inflammatory connective tissue diseases such as systemic lupus erythematosus (SLE) or dermatomyositis, given the combination of cutaneous and articular symptoms.

Treatment Plan

A treatment plan is pending a definitive diagnosis. The patient was advised to continue avoiding any new topical agents. Symptomatic management for pruritus with over-the-counter antihistamines could be considered in the interim. A definitive therapeutic strategy will be based on the findings from further evaluation.

Outcome and Follow-up

The patient was instructed to provide comprehensive photographs of the affected areas as requested. A follow-up consultation is scheduled to review the images. Further recommended steps will likely include an in-person physical examination, a skin biopsy for histopathological analysis, and a panel of blood tests, including a complete blood count (CBC), comprehensive metabolic panel (CMP), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and an antinuclear antibody (ANA) panel to investigate for underlying systemic disease.