Dorsum Of Hand Research Articles

Efektivitas Monitoring Glukosa Darah dengan Pengambilan Sampel di Telapak Tangan Terhadap Penurunan Nyeri Akibat Tusukan Jarum pada Pasien Diabetes Mellitus

This literature study aims to determine Effectiveness of Blood Glucose Monitoring by Sampling on the Palm of the Hand in Reducing Needlestick Pain in Diabetes Mellitus Patients. The research design is a systematic review, using 6 databases, ProQuest, EMBASE, SpringerLink, Sage Journals, Scopus and Taylor and Francis. A total of 10 articles were reviewed from 2010 to 2022. The keywords used in the literature search were Diabetes Mellitus AND Blood Glucose AND pain AND palm site AND fingertip. The protocol and literature review evaluation used the Critical Appraisal Skills Program issued by the JBI Guideline. The results of the study showed that the palms of the hands as blood glucose sampling sites were effective in reducing pain due to needle pricks in patients with diabetes mellitus. In addition, pain can also be minimized by adjusting the diameter of the lancet and the depth of the puncture and using the latest technology/method for testing blood glucose. In conclusion, palms as an alternative site for blood glucose sampling are effective in reducing pain due to needle pricks in patients with diabetes mellitus.
 
 Keywords: Diabetes Mellitus, Blood Glucose, Pain, Palms, Fingertips

Usefulness of the lateral arm free flap for hand defect reconstruction

Purpose: Although various surgical reconstruction methods are available for multidigit defects or soft tissue defects of the hand, they often require a thin flap due to the hand’s unique physical characteristics. We performed a total of 13 cases of lateral arm free flap surgery at our hospital. The purpose of this study was to report the usefulness of this technique. Methods: This study included the following cases: four cases of multiple digit amputations, seven cases of hand dorsum skin defects, one case of first web reconstruction due to web contracture, and one case of an index finger bone and soft tissue defect with only the ulnar-side neuro-vascular bundle remaining. After emergency simple debridement, subsequent reconstruction was performed using a lateral arm free flap. Results: All 13 cases healed without necrosis. Patients who underwent finger amputation were able to preserve the length of their fingers without any additional amputation. Patients who initially had hand dorsum defects were able to maintain grasping function after flap stabilization. The patient with web contracture was able to recover the lost pinching function, and the patient with a combined loss of osteoarticular and soft tissue of the index finger maintained the shape and length of the finger despite the absence of joint function. Conclusion: The lateral arm free flap is a useful reconstruction method that can be easily performed with a single session of regional anesthesia. Since the flap is thin, it is suitable for hand defect reconstruction. If necessary, vascularized bone grafting is possible.

Sclerotherapy off the Lower Extremities: A Single-Center Retrospective Study of Veins Treated on the Dorsal Hands and Chest.

Few studies have evaluated the safety and efficacy of treatment of cosmetic dorsal hand and chest/breast veins. To retrospectively evaluate results of dorsal hand and chest vein foam sclerotherapy. A retrospective chart review of dorsal hand and chest vein sclerotherapy patients at a dermatology practice was performed between January 2014 and April 2023. Fifty-five patients (54 female and 1 male patients) with a mean age of 55.8 ± 10.5 (31-83) years underwent treatment. Mean number of sessions for dorsal hand ( n = 41) and chest ( n = 14) patients were 1.5 ± 0.9 (1-5) and 1.6 ± 1.2 (1-5), respectively. Both groups were predominantly treated with 0.2% sodium tetradecyl sulfate or 0.5% polidocanol foam. Rate of coagulum formation across all sessions in the dorsal hands and chest was 15.2% and 3.0%, respectively. Vein induration, edema, postsclerotherapy hyperpigmentation, and persistent erythema were rarely seen. No patients experienced superficial venous thrombophlebitis, erosion/ulceration, telangiectatic matting, or neurologic side effects. Seventy-five percent and 63.2% of chest and hand patients, respectively, demonstrated significant clinical improvement at 3-month follow-up, although not systematically evaluated. Foam sclerotherapy of dorsal hand and chest veins with detergent sclerosing agents is safe and effective with mild, self-limited adverse events.

Design of a low-frequency ultrasound diagnostic sensor based on skin mechanical impedance

Skin integrity assessment is a very important matter in the nursing care, especially for patients with low mobility. However, the methodology of skin analysis is limited by a lack of reliable yet portable tools. In this paper, a new sensor is proposed for skin mechanical impedance characterisation, aiming to provide an objective assessment of skin health. The device consists in a microcontroller connected to a Langevin transducer. Using the vector control method, the reference vibration of the transducer is assured, and the mechanical impedance is observed. To ensure the repeatability of the measurements, tests in the morning and in the afternoon were taken. To verify if the device can distinguish sites with different mechanical properties on the same body, tests were made on 2 different body sites: the palm of the hand and the volar forearm. Measurements of skin hydration were also taken, to find a potential correlation of these parameters and skin acoustical mechanical impedance. Results have shown that the measurements provided by the device are mostly reliable, and reveal a fair correlation between mechanical impedance and hydration, in the level of stratum corneum, the outermost layer of skin. Also, the device is able to show the difference on the mechanics of the skin in the different body sites tested, independently of the hydration.

Remitting seronegative symmetrical synovitis with pitting edema syndrome postsecond COVID-19 vaccination: a case report.

A 52-year-old woman presented with hand edema, arthralgia, and morning stiffness, after receiving the second dose of m RNA COVID-19 vaccination. Examination revealed edema in the dorsum of both hands and symmetrical tenderness of the shoulders, elbows, wrists, knees, and ankles. Blood test results were normal except for elevated levels of C-reactive protein. The immune profile and the tuberculin test were also negative. A hand radiograph showed soft tissue edema. Ultrasonography of the extremities has shown tenosynovitis. Remitting seronegative symmetrical synovitis with pitting edema syndrome was diagnosed according to the diagnostic criteria. She was treated with 30mg/day prednisolone, with a complete disappearance of edema and arthralgia after 10 days, and the C-reactive protein level was decreased. Vaccines are still the most effective and protective method against COVID-19 infection, but it may trigger an immunological response. Remitting seronegative symmetrical synovitis with pitting edema (or sometimes RS 3 PE) is a rare nonunderstood syndrome identified by symmetric polyarthritis, synovitis, acute pitting edema of hands and/or feet, and a negative serum rheumatoid factor, with an excellent prognosis to treatment with steroid. Usually occurred in the old aged population, young patients' cases were mentioned. As the authors did not find any data about our subject, this is the first case of this syndrome development after the second dose of COVID-19 vaccination. The occurrence of acute symmetrical seronegative polysynovitis with extremities edema, in the elderly, should guide toward the diagnosis of this syndrome.

Peran Intelijen dalam Keberlangsungan Demokrasi dan Hak Asasi Manusia di Indonesia

This paper discusses the dynamics of the role of intelligence in the reform era in relation to democracy and human rights. Intelligence reform places intelligence more ideally attuned to reform values. However, intelligence practices in the reform era were not as perfect as imagined. In this paper, there are intelligence opportunities and challenges in the future, as part of intelligence development efforts. This paper uses the theory of democratic intelligence owned by Uri Bar-Joseph. The conclusion of this paper is that intelligence as a tool of state security institutions can also have a great opportunity to promote democratic values if law enforcement is really implemented. However, these efforts are not as easy as turning the palm of the hand, because intelligence is still facing challenges that have not been resolved to date.

Neutrophilic dermatosis of the dorsal hands treated with baricitinib.

A localized variant of Sweet syndrome treated with baricitinib.

Case of Generalized Granuloma Annulare Treated with Low Dose Naltrexone + PUVA

Granuloma annulare (GA) is a common, noninfectious granulomatous skin condition that usually presents in its localized form, characterized by flesh-colored to erythematous papules coalescing into annular plaques without scale, commonly on the dorsal hands. Lesions can be pruritic and often resolve without treatment in two years. However, the generalized form of GA has a lower incidence and presents with similar morphology, but with >10 lesions in a widespread distribution. Generalized GA is known to be more symptomatic, longer-lasting, and recalcitrant to treatment. The diagnosis is made based on clinicopathological correlation with palisading granulomas around degenerated collagen in the dermis, mucin, and infiltrative lymphocytes and histiocytes. Treatment remains challenging as evidence is limited to case reports, case series, and a few retrospective studies. Here we present the case of a 59-year-old Caucasian female with pruritic rash that began on her abdomen and spread to her extremities over two months. Biopsy revealed superficial histiocytic infiltrates palisading around eosinophilic areas of altered collagen, multiple multinucleate giant cells with elastophagocytosis and lymphohistiocytic perivascular infiltrates, and mucin in the dermis on colloidal iron staining. Overall, this was consistent with generalized GA. The patient was started on a combination of low dose naltrexone (LDN) and psoralen and ultraviolet A (PUVA) therapy. At a five-month follow up visit, she demonstrated near complete resolution of symptoms without any serious adverse effects.

The impact of alcohol‐based hand sanitiser and hand washing with soap and water on bacterial skin microbiota composition

AbstractBackgroundThe use of alcohol‐based hand sanitiser (ABHS) and hand washing with soap and water increased during the COVID‐19 pandemic.ObjectivesWe aimed to determine the immediate impact (<1 h) of hand hygiene measures on sampling and profiling of the bacterial skin microbiota.MethodsSkin swab samples were collected from the dorsal hand and inner elbow from five volunteers before and after application of ABHS and before and after washing hands with soap and water. Bacterial composition was determined by MiSeq sequencing of the 16S rRNA gene.ResultsBacterial composition on the hands was similar before and after application of hand sanitiser, with Streptococcus spp. (19.3%–18.4%), Propionibacterium spp. (11.7%–11.9%), Corynebacterium spp. (11.2%–11.3%) and Staphylococcus spp. (7.8%–7.4%) as the most prevalent genera. The relative abundance of bacteria changed after hand washing with soap and water for Streptococcus spp. (15.7%–9.2%), Propionibacterium spp. (12.1%–8.3%), Staphylococcus spp. (8.2%–5.2%) and Lactobacillus spp. (7.1%–2.9%). For alpha diversity, the number of amplicon sequence variants (ASVs) on the hand was lower after washing with soap and water: mean: 94.6 (SD: 12.3) versus before: 165.5 (SD: 12.7), p = 0.003. The ASV richness did not differ before and after hand sanitiser application (p = 0.2 for both hand and inner elbow). The Faith PD index was lower after washing with soap and water: mean: 6.6 (SD: 0.41) compared to before (9.5 [SD: 0.52]), p = 0.002, but no change was seen for application of hand sanitiser on hand (p = 0.3) or elbow (p = 0.5).ConclusionsSkin microbiome diversity did not differ before and after hand sanitiser application but was lower after washing with soap and water, perhaps due to the mechanical removal of bacteria during hand washing. Both Gram‐negative and Gram‐positive bacteria were affected, with the largest impact on the Gram‐negative bacteria.

Cutaneous vascularization of the proximal two-thirds of the dorsal aspect of the hand: descriptive anatomical study of a perforating arterial arch.

Several reports have suggested that transverse arches between the radial and ulnar sides of dorsal hand skin supply the proximal part of the skin. The main objective of the study was to provide an anatomical and radiological description of a superficial vascular arch in the proximal third of the metacarpals of the long fingers. We dissected 11 hands after injection with a mixture of lead and resin. A CT scan was performed before dissection. All vessels supplying the skin were individualized on the back of the hand and measured. A superficial perforating dorsal arch of the hand was present in all cases in this study. It was supplied by a dorsal radial perforating artery arising from the radial artery and by a dorsal ulnar perforating artery arising from the dorsal carpal arch. The distal recurrences of the intermetacarpal spaces communicated with this arch. This arch was the only source of vascularization of thess proximal third of the third space and presented a dominant ulnar side in the majority of cases. It presented numerous anatomical variations. The source vessels had mean diameters of 0.5mm. There was an excellent radiological-anatomical correlation on CT scan. Given the constancy of this arch in the study, perforating flaps not yet described could be considered, having as pivot points the ulnar or radial origin of this arch.

Red Palms' Syndrome and Red Fingers' Syndrome: A Mini Review.

Red palms syndrome consists of an intense redness on the palms of the hands and, occasionally, the soles of the feet. This infrequent condition may be primary or secondary. The primary forms are either familial or sporadic. They are always benign and do not require treatment. The secondary forms may have a poor prognosis related to the underlying disease, for which early identification and treatment are imperative. Red fingers syndrome is also rare. It manifests as a persistent redness on the fingers or toes pulp. It is typically secondary either to infectious diseases like human immunodeficiency virus, hepatitis C virus and chronic hepatitis B or to Myeloproliferative Disorders, such as Thrombocythemia and Polycythemia vera. Manifestations spontaneously regress over months or years without trophic alterations. Treatment is limited to that of the underlying condition. Aspirin has been shown effective in Myeloproliferative Disorders.

Visible-light optical coherence tomography platform for the characterization of the skin barrier.

We demonstrate a free-space, trolley-mountable Fourier domain visible-light optical coherence tomography (OCT) system for studying the stratum corneum in non-palmar human skin. An axial resolution of 1 µm in tissue and at least -75 dB sensitivity have been achieved. High-quality B-scans, containing 1600 A-scans, are acquired at a rate of 39 Hz. Images from the dorsal hand, ventral wrist and ventral forearm areas are obtained, with a clearly resolved stratum corneum layer (typically 5-15 µm thick) presenting as a hypoechogenic dark layer below the bright entrance signal, similar to that found in palmar skin with traditional OCT systems. We find that the appearance of the stratum corneum layer strongly depends on its water content, becoming brighter after occlusive hydration.

A novel telomerase activity and microRNA-21 upregulation identified in a family with palmoplantar keratoderma

Palmoplantar keratoderma is a set of skin diseases with hyperkeratotic thickening of palms and soles which are characteristic of these heterogeneous group of keratinization disorders.Various genetic mutations, autosomal dominant or recessive, have been identified which may triggerpalmoplantar keratoderma, as KRT9 (Keratin 9), KRT1 (Keratin1), AQP5 (Aquaporin), SERPINB 7 (serine protease inhibitor). The identification of causal mutations is extremely important for the correct diagnosis. Here, we report the case of a family affected from Palmoplantar keratoderma caused by autosomal dominant KRT1 mutations (Unna-Thost disease).Telomerase activation and hTERT expression take a part in the process of cell proliferation and inflammation and microRNAs, as microRNA-21, are emerging as drivers in the regulation of telomerase activity.Here, the patients underwent KRT1 analysis genetic sequence, telomerase activity and miR-21 expression. Beside histopathology assay was performed. The patients presented thickening of the skin on soles of the feet and the palms of the hands, KRT1mutations and showed high expression levels of hTERT and hTR, the gene encoding for the telomeric subunits, and miR-21 (fold change > 1.5 and p value = 0.043), explicating the aberrant proliferation of epidermal layer and the inflammatory state characterizing palmoplantar keratoderma.

Waardenburg syndrome - Report of two cases

Waardenburg syndrome (WS) is a group of genetically heterogeneous disorders characterised by white forelock of hair, heterochromia irides, blue eyes, and sensorineural hearing loss as main characteristics. A 3-year-old girl presented with pre-lingual deafness and mild delay in developmental milestones. Both parents were deaf since childhood. On examination, she had a white forelock, heterochromia iridium, dystopia canthorum and hypopigmented areas noted in the distal end of all four limbs. A 1-year-old girl presented with pre-lingual deafness. Other milestones are normal for age. On examination, the baby was not responding to sound, and white forelock, heterochromia iridium, dystopia canthorum and hypopigmented skin over the dorsum of hands and legs were present. Mother also has a white forelock and dystopia canthorum. Brain stem auditory-evoked potentials in both cases showed bilateral auditory pathway dysfunction. Based on the above findings, a diagnosis of WS type-1 (WS-1) was made in both and confirmed by genetic testing. Clinical features of the skin, hair changes, and hearing impairment with language delay with a family history that we should consider WS-1.

Giant Lipoma of the Hand: An Exceedingly Rare Condition!

Lipomas are the most common benign form of soft tissue tumor in the body. Although they are commonly found on the upper extremity, their occurrence in the hand is rare. Giant lipomas of the hand, defined as >5 cm in diameter, are extremely rare. This manuscript reports a very rare case of giant lipoma on the palmar side of the hand in order to study the diagnostic, theurapeutic and prognostic aspects. A 61 year-old female had a large asymptomatic thenar swelling since 10 years. The clinical examination showed a subcutaneous tumor spreading the 1st commissure and making opposition of the thumb very limited. There were no inflammatory signs and no pain. The patient didn’t report any sensory deficit and the neurological examination was normal. The standard X-ray showed a tissue image without bone lesions. MRI demonstrated a large, well-limited T1, T2 hypersignal tissue formation, which developed in the subcutaneous fat of the first commissure, insinuated itself in front of the last three metacarpals, and included the deep and superficial flexor tendons. The patient was operated on under local anesthesia and pneumatic tourniquet at the root of the limb. The approach allowed a satisfactory exposure of the entire palm of the hand and revealed a lipomatous mass, encapsulated, pushing back the vascular and neural pedicles of the long fingers without invading them and remaining in front of the flexor tendons. The tumor was carefully dissected, which allowed it to be removed totally. Histology confirmed the diagnosis of benign lipoma. Complete recovery was achieved without any sign of recurrence during a follow up period of 5 years. Lipomas of the hand represent a rare benign tumor pathology; giant lipomas represent an exceedingly rare condition. The proximity of the relationships with the vascular and neural structures must lead to the greatest caution during surgical dissection. Only anatomopathological examinations confirm the histological nature of the lesion.

Reconstruction of Hand Dorsum Defect Using Double Perforators-Based Anterior Interosseous Artery Island Flap: A Case Report and Description of a New Anterior Interosseous Artery Perforator.

The anterior interosseous artery (AIA) perforator flap is not commonly used in hand dorsum reconstruction compared with alternatives. However, it is a versatile flap with several advantages. Literature on the AIA perforator flap is based on the dorsal septocutaneous branch (DSB), which branches from the AIA and passes through fascia between the extensor pollicis longus (EPL) and extensor pollicis brevis muscles. In the described case, the authors reconstructed a hand dorsum defect in a 78-year-old man using an AIA perforator flap with double perforators supplied by the DSB and a new perforator branching from the distal than DSB. No complication was encountered, and the flap survived completely. A retrospective computed tomography review revealed the presence of the new perforator in 14 of 21 patients. Two types of new perforator were observed. One passed through the ulnar side of the extensor indicis proprius (EIP) muscle and penetrated fascia between the extensor digitorum minimi and extensor digitorum communis tendons, whereas the other passed between the EPL and EIP muscles. This report describes the anatomical location and clinical application of the new AIA perforators. The double perforators-based AIA flap provides a straightforward, reliable means of reconstructing hand dorsum defects.

Neurodermatitis in Baquba City, Diyala Governorate/Iraq Clinical and histopathological study

Background: Many patients that have itchy thickened skin lesions are lichenified, it's located on the extremities namely on the knees, feet, dorsum of the hands, and /or elbows was being seen bilaterally and may be symmetrically. Objective: To evaluate clinical and histopathological features of neurodermatitis with some similarities to psoriasis in Iraqi patients. Patients and Methods: Twenty- Five patients with neurodermatitis attending Department of Dermatology, Baquba Teaching Hospital were enrolled in this study in time between 1st January 2020 to 31th January 2021. All patients were being examined and full history was taken, including age of the patients, onset and duration of the disease, severity and type of itching. A full examination was done to identify the character, colour, shape, site, and involvement of other body site of lesion. Incisional biopsy specimens from both lesion and adjacent normal skin were obtained from 9 patients and submitted to histological assessment. Results: Ten of the patients (40%) were male and fifteen (60%) were females, their age ranged from 29-70 years, with a mean of 49.5 years. The average duration ranged from one month- 15 years with median 7.5 years. Clinically; patients have severe itchy plaques that distributed bilaterally like those of psoriasis, involvement of the knees (56%), dorsum of the both hands, feet, and elbows, also having ( lichenification ,that is characterized by thickening of the skin and exaggeration of the skin lines ) which characteristic of the individual lesion of lichen simplex chronicus, these plaques were symmetrical, well defined, sharper, more keratotic, violaceous pigmentation, marked accentuation and thickening of skin. Psoriatic scales are not present typically on the plaques of these patients. These plaques mainly located on extremities. Nine specimens' taken for histopathologiacl findings showed hyperkeratosis, acanthosis, dermal papilomatosis, suprapapillary epidermal thinning. All patients mentioned a severe itching which was paroxysmal in typing, more severe in the evening. Conclusion: ( Lichenified psoriasis) Psoriatic neurodermatitis might be lichen simplex chronicus as a result to repetitive itching and scratching of plaque psoriasis. This was typical neurodermatitis and not psoriasis. Keywords: Psoriatic neurodrmatitis,Lichenification, Plaque psoriasis

Neurodermatitis in Baquba City, Diyala Governorate/Iraq Clinical and histopathological study

Background: Many patients that have itchy thickened skin lesions are lichenified, it's located on the extremities namely on the knees, feet, dorsum of the hands, and /or elbows was being seen bilaterally and may be symmetrically.
 Objective: To evaluate clinical and histopathological features of neurodermatitis with some similarities to psoriasis in Iraqi patients.
 Patients and Methods: Twenty- Five patients with neurodermatitis attending Department of Dermatology, Baquba Teaching Hospital were enrolled in this study in time between 1st January 2020 to 31th January 2021. All patients were being examined and full history was taken, including age of the patients, onset and duration of the disease, severity and type of itching. A full examination was done to identify the character, colour, shape, site, and involvement of other body site of lesion. Incisional biopsy specimens from both lesion and adjacent normal skin were obtained from 9 patients and submitted to histological assessment.
 Results: Ten of the patients (40%) were male and fifteen (60%) were females, their age ranged from 29-70 years, with a mean of 49.5 years. The average duration ranged from one month- 15 years with median 7.5 years. Clinically; patients have severe itchy plaques that distributed bilaterally like those of psoriasis, involvement of the knees (56%), dorsum of the both hands, feet, and elbows, also having ( lichenification ,that is characterized by thickening of the skin and exaggeration of the skin lines ) which characteristic of the individual lesion of lichen simplex chronicus, these plaques were symmetrical, well defined, sharper, more keratotic, violaceous pigmentation, marked accentuation and thickening of skin. Psoriatic scales are not present typically on the plaques of these patients. These plaques mainly located on extremities. Nine specimens' taken for histopathologiacl findings showed hyperkeratosis, acanthosis, dermal papilomatosis, suprapapillary epidermal thinning. All patients mentioned a severe itching which was paroxysmal in typing, more severe in the evening.
 Conclusion: ( Lichenified psoriasis) Psoriatic neurodermatitis might be lichen simplex chronicus as a result to repetitive itching and scratching of plaque psoriasis. This was typical neurodermatitis and not psoriasis.

Reformasi Pendidikan Nasional

<p> </p><p>This journal tries to describe common problems that often arise in the world of national education, especially in Indonesia. Education which was originally a bridge to realize a complete human being cannot be separated from various kinds of problems, ranging from problems of facilities and infrastructure, the gap between what is learned and taught in school With the problems of life that occur around, the irrelevant output of the world of education with the needs of the world of work , limited opportunities for education in schools to the sad fate of teachers as agents of change in educational institutions has always been a decoration of the mass media both print and electronic. To solve various kinds of problems, it is certainly not as easy as turning the palm of the hand, it takes awareness and cooperation of various parties so that these general problems can be eroded slowly, with the hope that the educational goals mandated by the founding fathers of the Indonesian nation can be realized. This journal, with all its limitations, tries to describe the various kinds of problems faced by the Indonesian people as well as offers steps to solve them</p>

DP12 Painful oral keratosis and skin lesions: a paraneoplastic diagnostic conundrum

Abstract A 70-year-old man was referred to oral medicine with extensive, painful oral hyperkeratosis affecting the tongue, buccal mucosa and palate. Medical history included a previous diagnosis of prostate cancer. Histology from multiple oral biopsy specimens showed only hyperparakeratosis and acanthosis, with no fungi or dysplasia. Owing to the absence of oral inflammation, the pain was treated as neuropathic. The patient then developed skin lesions and dermatology review was requested. Skin examination revealed marked hyperkeratotic, verrucous plaques affecting the extensor surfaces of the limbs and dorsal hands, as well as the plantar feet bilaterally. The nails were unaffected. There was violaceous discolouration of the pinnae. Given the history of prostate cancer, a paraneoplastic process was suspected. Two incisional biopsies were taken, which showed epidermal acanthosis with necrotic and dyskeratotic keratinocytes throughout the epidermis. There was a dense eosinophilic inflammatory infiltrate. Direct and indirect immunofluorescence was negative. The appearances were suggestive of a paraneoplastic phenomenon, including acrokeratosis paraneoplastica. Haematological investigations identified an IgG monoclonal paraproteinaemia with raised kappa:lambda ratio. Following further investigation, including bone marrow biopsy and positron emission tomography computed tomography, a diagnosis of monoclonal gammopathy of undetermined significance was made by haematology. A repeat bone marrow biopsy 7 months later confirmed evolution to myeloma. As CRAB criteria (hypercalcaemia, renal insufficiency, anaemia and bone lesions) were absent, a period of observation followed. A trial of oral steroids improved the cutaneous eruption, but he developed significant side-effects. Oral mycophenolate, methotrexate and acitretin were used as steroid-sparing agents, with a poor clinical response. The skin lesions progressed to a widespread psoriasiform eruption on the trunk and lower limbs with the formation of bullae. Further biopsies showed an eosinophil-rich infiltrate with negative immunofluorescence, raising the possibility of an eosinophilic dermatosis of haematological malignancy. After 2 years, given the worsening skin symptoms, it was decided to commence bortezomib, cyclophosphamide and dexamethasone (VCD) chemotherapy. Despite four cycles of VCD treatment, the skin lesions worsened and as the paraprotein levels did not reduce, treatment was stopped. Subsequently, further elevations in serum free light chains prompted treatment with lenalidomide. This resulted in a marked improvement in the skin and reduced pain from the oral lesions, as well as a reduction in serum free light chains. Acrokeratosis paraneoplastica (Bazex syndrome) is characterized by digital hyperkeratosis and paronychia, which may progress to involve the limbs and trunk. Eosinophilic dermatosis of haematological malignancy is characterized by a pruritic, papular skin eruption with a vesiculobullous component. This case presents a diagnostic conundrum, with evolving features of two different paraneoplastic conditions.