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Case Reports

Abstract

A 58-year-old female with past medical history of type 2 diabetes mellitus, hypertension, obesity, and multifactorial lower extremity ulcers presented to dermatology with a complaint of asymptomatic red, raised lesions involving the lower extremity, bilateral forearms, and abdomen. On examination, she had discrete red-brown papules and macules without ulceration involving the left lower leg and dorsum of the foot. She also had smaller cayenne pepper-colored macules on a background of reddish-brown patches on the bilateral flexural forearms.    

Punch biopsies from the left lower leg and right forearm revealed brisk superficial dermal non-necrotizing granulomatous inflammatory infiltrate with numerous extravasated erythrocytes. Iron stain highlighted significant deposition of iron within the superficial dermis. There was no evidence of infection, primary vasculitis or vasculopathy. These findings were most consistent with granulomatous pigmented purpuric dermatosis (GPPD).

This case highlights an interesting clinical presentation of granulomatous appearing violaceous to reddish brown papules on the lower extremity in addition to the “cayenne pepper” appearing red macules on the forearms consistent with the more classic findings of pigmented purpuric dermatosis (PPD). Histopathologically, the findings of granulomatous inflammation led to a diagnosis of GPPD, which is an unusual variant of PPD. Clinicians should include GPPD on the differential of granulomatous eruptions on the lower extremities, especially in cases where other features of PPD are also present.