An 80-year-old woman presents with a chief complaint of intermittently painful "bumps" on her left elbow that have been present for several years. She first noticed them shortly after she traumatized the elbow. The lesions have occasionally drained a chalky material.
On examination, you observe multiple small, discrete, yellow-white, firm papules over the elbow. There is minimal perilesional erythema (figure).
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Differential diagnosis
Skin conditions to consider are those that produce infiltrated yellow-to-white papules. Granuloma annulare may occur over the elbows and produce infiltrated papules, but these lesions do not drain any material.
Gouty tophi can appear as yellow-white papules over the elbow, identical to what is seen in this patient. Nevertheless, they tend to be multiple and symmetrical.
Rheumatoid nodules are a common occurrence in patients with rheumatoid arthritis (RA), particularly in those with a high serum rheumatoid factor. Aside from the fact that this patient did not have RA, rheumatoid nodules seldom occur in only a single site.
Epidermoid cysts are yellow-white in color, may drain material, and may be multi-lobulated. These nodules typically appear in hair-bearing areas, particularly the scalp. The elbow would be an unusual location for these cysts.
Calcinosis cutis is the correct diagnosis. This localized site of dystrophic calcification may appear after trauma, as in this case. The chalky material that drains from the lesions is calcium salt.
This patient preferred no therapy once she was assured that her lesions were not cancer. Treatment, when chosen, is by surgical excision.
Diagnostic pearl
Consider calcinosis cutis if a patient presents with yellow-white papules that drain a chalky material.
Dr. Levine is professor of medicine (dermatology), University of Arizona Health Sciences Center, Tucson.
Norman Levine, MD
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