This is a particularly challenging case. The images above are from a patient who noted acute onset nonpitting edema of the arm. This later became a symmetric induration with puckering, giving the irregular, woody texture of the skin of an orange peel. The disease spares the hands and feet. When you raise the affected limb, visible indentations appear along the course of the superficial veins. The patient also complains of arthritis. Labs surprise you with an eosinophilia.Challenge: What is your diagnosis?
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Scar (Not Escar)
This is eosinophilic fasciitis or Shulman's syndrome. It is characterized in the early phase by limb or trunk erythema and edema and later by collagenous thickening of the dermis and subcutaneous fascia. The skin shows a peau d'orange appearance and the finding with raising the limb is called the groove sign due to sparing of the epidermis and superficial dermis.
Sources: UpToDate; dermatology.cdlib.org.
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