ACADEMIC EMERGENCY MEDICINE • June 1999, Volume 6, Number 6 637 CLINICAL PRACTICE Clinical Pearls: Ulcers on the Fingers DAVID E. MANTHEY, MD, DANIEL J. SCHISSEL, MD Figure 1. The patient’s left thumb. Figure 2. The patient’s right index finger. Chief Complaint. Ulcers on the thumb and index finger. History of Present Illness. A 68-year-old woman presents to the ED for evaluation of ulcers on her left thumb and right index finger that appeared after minor trauma. The lesions began as tender erythematous nodules, which progressed and coa- lesced to pustules. The pustules gradually became more erythematous and began to ulcerate. A dusky hue developed around the margins of the ulcers. This process occurred over a ten-day period. The patient states she had a similar ulcerative process on the buttock and upper thigh region. Treatment at that time included surgical resection of the lesions, which resulted in spreading of the lesions. Subsequently, she was evaluated by a der- matologist and started on oral corticosteroids. The ulcerations slowly resolved, leaving her with large hypertrophic reticulated scars. She denies chemical exposure or arthropod en- venomation. She denies diarrhea, bloody stool, fe- vers, headaches, and joint pain. Physical Examination. The patient’s physical examination is normal except for the hands, which reveal 2.7-cm ulcerated lesions on the left thumb (Fig. 1) and a 1.7-cm lesion on the distal aspect of the right index finger (Fig. 2). The lesions have well-defined dusky undermined borders. The base of both ulcers consists of granulation and necrotic tissue. From the Departments of Emergency Medicine (DEM) and Dermatology (DJS), Brooke Army Medical Center, San Anto- nio, TX. Section editor: Lawrence B. Stack MD, Vanderbilt University Medical Center, Nashville, TN. Photographic critique: Michael A. Morris, University of Arkan- sas for Medical Sciences, Little Rock, AR. Received February 10, 1998; revision received October 1, 1998; accepted October 14, 1998. This article represents the views of the authors and is not to be interpreted as official, or representing the US Army, US Air Force, or the Department of Defense. Address for correspondence and reprints: David E. Manthey, MD, Department of Emergency Medicine, Brooke Army Medi- cal Center, 3851 Roger Brooke Drive, San Antonio, TX 78234- 6200. Fax: 210-916-2265; e-mail: demanthey@aol.com Laboratory Studies. The patient has a normal white blood cell count and a normal erythrocyte sedimentation rate. (The diagnosis and discussion appear on page 655.)