Vol 126, No. 6, June 2008 Archives Clinical Challenge: You Make the Diagnosis Multiple Facial Papules and Palmar Pits REPORT OF A CASE A 73-year-old white woman presented with a 10- to 15-year history of countless small papules on her nose, nasolabial folds, lips, and chin. She reported that her sister as well as her mother had presented with similar papules in their fifties. Her mother had a history of her skin “pricking” instead of sweating, and the patient described herself as “not sweating easily.” Her grandmother had rheumatoid arthritis, and her mother had arthritis of unknown etiology. There is no other known family history of autoimmune disorders, and her only brother was unaffected. A physical examination revealed hundreds of nontender, round, skin-colored to whitish, 2- to 4-mm papules (Figure 1). She had many small 1- to 2-mm shallow pits on her palms. Scars were evident from prior treatment of several lesions. Shave biopsy specimens were obtained from the patient’s chin for microscopic examination (Figure 2 and Figure 3). What is your diagnosis? Figure 1. View a larger version of Figure 1 Figure 2. View a larger version of Figure 2 Figure 3. View a larger version of Figure 3 Please e-mail your diagnosis to dermquiz{at}ama-assn.org. You must include your full name, mailing address, and institutional affiliation in the initial e-mail to be eligible to enter the quiz. The first correct respondent will be acknowledged on this site next month and in print in Archives of Dermatology and will also receive a free copy of The Art of JAMA II. For a complete presentation of this case and an in-depth discussion of the entity, please see next month's edition of the Archives. Congratulations to the winner of our May quiz, Tahir Anis, MCPS, Institute of Skin Diseases, Karachi, Pakistan. The correct answer to our May challenge was necrolytic migratory erythema and glucagonoma syndrome. For a complete discussion of this case, see the Off-Center Fold section in the June Archives (Nussbaum KC, Barlow KC, Berk MA, Robinson N, Levit F. Erosive dermatitis and progressive neurological symptoms. Arch Dermatol. 2008;144[6]:795-800). Next month's quiz will be available on July 14, 2008, at 3 pm Central time.