ctinical and Experimental Dermatology 1991; 16: 204-206 Erythema elevatum diutinum—an unusual association with ulcerative colitis K.BUAHENE, M.HUDSON,* A.MOWAT,* L.SMARTf AND A.D.ORMEROD Departments of Dermatology, Gastroenterology* and Pathologyf Aberdeen Royal Infirmary, Aberdeen AB9 2ZB, UK Accepted for publication 28 Octoher 1990 Summary We report the association of erythema elevatum diutinum (EED) with ulcerative colitis (UC). The patient, whose history included rheumatoid disease, diabetes mellitus (type I) and hypothyroidism developed EED during a severe aeute exacerbation of UC which resolved following colectomy. To our knowledge this is the first report of such an association. Also of interest was the observation of Koebner phenomenon occurring at the sites where blood vessels were damaged. Erythema elevatum diutinum (EED) is an uncommon cutaneous lesion which was first described in 1894 by Crocker and Williams' to characterize an unusual derma- tological finding observed in a small group of patients. These consisted of symmetrical erythematous, purple nodules and plaques with a tendency to develop in the vicinity of articulations of the extremities. Classically these lesions are often located on the extensor surfaces of the joints of the hands, elbows and knees and are not uncommon on the buttocks and shins. The lesions are depressed centrally with a raised and sometimes nodular edge. The age of onset is usually between 30 and 60 years.^ Neither sex predominates. There is no familial incidence, apart from a single family involving a mother and daughter.' The aetiology and pathogenesis ofthe disease are unknown, but the histopathological process is a leucoeytoclastic angiitis which can be followed by late fibrotic changes. An auto-immune complex Arthus-type reaction may be the triggering event as there are similarities in the spectrum and neutrophilie vasculitis reactions between EED, Sweet's syndrome^' and pyo- derma gangrenosum. Correspondence: Dr A.D.Ormerod, Ward 29, Dermatology, Aber- deen Royal Infirmary, Foresterhill, Aberdeen AB9 2ZB, UK. On 12 October 1989 this patient was presented to a meeting ofthe Scottish Dermatology Society. We believe that the EED in this patient represents a hitherto unreported dermatological manifestation of UC. Case report A 58-year-old woman presented in April 1989 with 5 months' history of diarrhoea and the passage of fresh blood with the stool. The patient had a previous history of rheumatoid arthritis, hypothyroidism and insulin-depen- dent diabetes mellitus controlled with daily Mixtard, in addition to 100 ^g of thyroxine per day. Salazopyrin (10 g daily) was introduced after UC was diagnosed on both clinical and histological examination. The rectal biopsy revealed a severe active chronic UC with evidence of epithelial dysplasia. She required parenteral methylpred- nisolone and blood transfusion for a hypochromic micro- cytic anaemia but despite troublesome proximal faecal stasis, symptoms settled on this treatment over a 4-week period. She was referred to the Dermatology Department in May 1989 with an eruption beginning at the sites of intravenous cannulae insertions on the dorsal aspects of both hands which had extended into large plaques. Examination revealed symmetrical erythematous plaques over the dorsa ofthe hands and knuckles w hich were firm and raised becoming nodular with superticial blistering at the edge and with some central clearing (Fig. 1). The plaques were painful and tender. Although the lesions started at the sites of needle trauma suggestive ofthe Koebner phenomenon they had extended on to the extensor aspects of the elbows and neck region. She did not develop lesions at the site of daily insulin injections into the subcutaneous tissues but after an intravenous injection of glucagon for hypoglycaemia, developed a Koebner response (Fig. 2). Abnormal investigations were as follows: ESR, 74 mm in the first hour; alkaline phosphatase, 271 i^gjl; y- glutamyl transferase, 80 /ig/1; rheumatoid factor, 347 iu/ ml; Rose-Waaler test, 4:128. Immunoglobulin assay: IgG and IgA at 14-8 and 3 8 g/1, respectively, but the serum IgM level was within the normal range. 204