Underneath the “apple-jelly”

A 44-year-old Caucasian woman presented with asymptomatic skin lesions on the trunk, arms and legs. These lesions had suddenly appeared 4 months before and have been unchanged ever since. Medical history included arterial hypertension and hypertriglyceridemia. The patient recalled an acute episode of painful subcutaneous nodules on the lower legs some years ago that disappeared with NSAID and leg rest. On physical examination, we observed a bilateral and symmetric dermatosis composed of multiple well-defined erythematous papules and plaques involving the trunk, arms and legs, and sparing the face, acral sites and mucosae. Some of the papules appeared to be pseudovesicular with a yellowish hue (Figure 1). Further dermoscopic examination disclosed multiple orange and yellowish globules and structureless areas in combination with linear vessels (Figure 2). A 4 mm punch biopsy was performed. Histopathological examination revealed an unchanged epidermis and organized collections of epithelioid histiocytes on the superficial and deep dermis (Figures 3 and 4). Underneath the “apple-jelly”