Subtle periorbital edema and hyperkeratotic papules in a woman of color.

A 65-year-old African-American female presented to the der- matology clinic complaining of poorly controlled melasma over the past year. Physical examination incidentally revealed bilateral violaceous periorbital erythema and edema, accen-tuated on the left eye, patchy gray to violaceous pigmented patches on forehead and glabella, and flat-topped, hyperkeratotic papules overlying the metacarpophalangeal and proximal interphalangeal joints (Fig. 1). Upon further inspection with capillaroscopy, periungual, dilated, looped telangiectasias were evident (Fig. 2). The patient denied proximal muscle weakness, fatigue, weight loss, shortness of breath, chest pain, or dyspnea on exertion. A punch biopsy above the left metacarpophalangeal joint was taken revealing perivascular lymphocytic infil- trate with epidermal hyperplasia, acanthosis, slight increase of papillary dermal mucin, and mild vacuolar interface at the der- moepidermal junction. Direct immunofluorescence revealed C5b-9 and weak IgM and C3 deposition with cytoid bodies along the epidermal basement membrane.