When an asymptomatic rash appeared rather suddenly on both of her legs, a 54-year-old woman sought medical evaluation by her primary care provider. He diagnosed contact dermatitis and prescribed triamcinolone cream 0.1%. Forty-eight hours later, with no signs of improvement evident, the patient seeks and is granted a same-day appointment with dermatology.

The patient denies any previous occurrences of such a rash and further denies having joint pain, fever, or malaise. She had not taken any new medications prior to the rash’s onset; furthermore, she only occasionally uses OTC medicines. A thorough history reveals that two days before the rash appeared, on one of the first hot days of the summer (with a temperature above 95°F), the woman played 18 holes of golf.

The rash itself is strikingly red and affects both lower legs symmetrically, from mid-calf to just above the ankles. There, it ends abruptly with a linear, transverse border. There is no tenderness or increased warmth appreciated on palpation, nor is there any nodularity, vesiculation, or other disruption of the skin’s surface. Distinct, complete blanching is noted on firm digital palpation.

ANSWER
The correct answer is golfer’s vasculitis (choice “d”), which favors older patients who spend extended periods on their feet in hot weather.

Schamberg’s disease (choice “a”), a type of capillaritis, presents with nonblanchable, true purpura that are classically described and seen as having a peculiar brown color (which has been called cinnamon or cayenne pepper).

Those who experience a true contact dermatitis (choice “b”) almost invariably itch and would most likely present with vesiculation of the skin surface.

Leukocytoclastic vasculitis (LCV; choice “c”) presents as a nonblanchable purpuric condition that, on biopsy, demonstrates classic findings of red blood cell (RBC) extravasation from venules damaged by neutrophils.

DISCUSSION
“Golfer’s vasculitis” has been described in nongolfers who are older and who have spent considerable time on their feet in hot weather. Fair-goers, amusement park patrons, and hikers are just as likely to develop it, but it was first studied in golfers—and at first, it was thought to represent a sensitivity to chemical grass treatment.

However, the lack of symptoms and vesiculation (blistering) suggested otherwise, and biopsies of the affected skin confirmed gravity-related hyperemia with mild extravasation of RBCs. They also failed to show any signs of contact dermatitis. The sharply defined linear inferior border of the rash is clearly caused by the compressive effects of socks, which prevent the leakage of RBCs.

The other items in the differential were rightly considered—particularly LCV, which can be associated with conditions such as hypersensitivity reactions to medications or can be a presenting sign of lupus and rheumatoid arthritis, among several other possibilities. But the key differentiating finding was the highly blanchable nature of this patient’s condition, in marked contrast to the nonblanchable, purpuric nature of classic LCV.

Often enough, blanchability is partial, or at least questionable, and a punch biopsy is necessary to clarify the picture. When histologic signs of LCV are found, blood work is necessary to rule out similar damage to “end organs,” such as kidneys and liver, as well as to attempt to establish the causative trigger.