A man in his 50s was referred to the dermatology clinic with a diagnosis of granuloma annulare made on the basis of prior skin biopsy results. He had been treated by a rheumatologist for polyarticular inflammatory arthritis involving the wrists, metacarpophalangeal joints, and proximal interphalangeal joints, as well as fatigue and dyspnea on exertion. Examination revealed numerous, pink-purple dermal papules on the trunk and extremities, with preference for the extensor surfaces of the arms (Figure, A) and legs. No lymphadenopathy was noted. The patient reported a 5- to 7-kg weight loss without fever or sweats. His pulmonary and joint symptoms were relieved by daily oral prednisone and flared with taper below 10 mg. Other medications prescribed included hydroxychloroquine, 400 mg, daily for 18 months and weekly adalimumab injections for 7 months, without improvement.
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