Hyperkeratosis, irregular acanthosis amounting to psuedoepitheliomatous hyperplasia and dermal infiltrate of lymphocytes and eosinophils are the salient features. Clinical picture and histology are suggestive of prurigo nodularis. The scaling around the nodules seen in clinical pictures and prominence of eosinophils in the infiltrate suggest that in addition, there is probably contact sensitization to some topically applied preparation. 

?Something cowpox-like or ORF?infection in a countryside worker...

....or a true verrucous carcinoma. Difficult. 

sir I wonder whether the patient was exposed to bromides etc

I would like to rule our halogenodermas

are the lesions elsewhere/acute onset

the other DD is Pemphigoid nodular

Many challenges lately. I see a Pseudoepitheliomatous hyperplasia along many mixed abscesses, many of them showing neutrophils and eosinophils. Do not see atypia. Special stains are necessary fot microorganisms, like fungus or mycobacteria. Leishmaniosis can do the same pattern of inflamation. More clinical information is necessary as we can see this pattern of inflamation in cases more uncommon like Halogenoderma (iododerma, bromoderma and fluoroderma). Halogenoderma can appear in patients after use of iodine contrast, use of anesthesics, etc.

This patient has chronic obstructive pulmonary disease and is on the following medications:

Alendronic acid, doxazocin, lisinopril, Evacal D3 D, amlodipine and the inhalers tiotropium bromide and Sirdupla (salmeterol 25mcg/fluticasone 250mcg) and salbutamol 200mcg, all which he had been on for many years. Does this help?

Ever seen before a Halogenoderma case. Great case and congratulation to all my Colleagues. 

Great. The tiotropium bromide should be the causative agent. Bromoderma.

Amazing case! Nodular papillomatous bromoderma. Occurs due to replacement of chlorine by bromine in the tissues. Doesn't disappear quickly after stopping bromide consumption but responds to intravenous administration of normal saline. Thanks for sharing! 

Thanks a lot sir for nice case

This was one of those cases in which we used a Sherlockian (as in Sherlock Holmes) approach. Once we have excluded all the common and less common possibilities (infections, lichenoid, neoplastic, granulomatous etc.) for pseudoepitheliomatous hyperplasia (PEH) there is only one diagnosis that fits, all be it very rare, and that is halogenoderma (neutrophils and eosinophils microabscesses in the absence of other known causes of PEH). In fact we used the rather wonderful review by Zayour and Lazova on pseudoepitheliomatous hyperplasia and there was only a single diagnosis with this combination of negative and positive findings. Once we had a possible diagnosis we took the simple step of going through the chemical structures of all the medications and the only ones that contained halogens were the inhalers!!!  We published this case as halogenoderma due to inhalers containing both bromine and flourine (fluticasone has fluouride ions). We believe this is the first such case in the literature although there was a mention in an old medical textbook and a comment that fluoroderma was more common on the legs. We postulated the location in our patient be due in part to poor venous return in a patient with COPD who is likely to spend much of the day sat chair bound. Steroids helped flatten the lesions. Would you believe one year later I colleague brought me a similar histology and after a few seconds I asked them was the patient COPD on inhalers. Answer yes. At that moment all the hairs on the back of my neck stood up!  The latter patient had had the lesion for 10 years and had previously be considered to have a carcinoma. Sometimes doing this specialty provides wonderful opportunities to make incredible diagnoses. Well done all for taking this challenge!!! I strongly suspect this condition is under-recognised but I'm still waiting for a 3rd case.

I note that if you type halogenoderma and inhalers into pubmed our paper does not come up (probably because of the title). One case does come up on a google search and may be our case  but I'm not 100% sure as I don't have access to the PDF but they appear to cite out paper.

An unusual case of multiple nodules on the lower legs.

Pseudoepitheliomatous hyperplasia: a review.

Thanks, Richard!!!!!!!!!!!!!

Great work. Thanks.

GREAT CASE!