Livid papules at the distal extremities in a 14‐year‐old girl

A 14-year-old girl presented with disseminated livid erythematous macules and papules with occasional central crusting, predominantly located at distal upper and lower extremities, especially at the dorsum of her hands and feet (Figure 1a, b). The skin lesions were sometimes itchy and slightly painful. The patient reported that the color of the skin lesions was variable and during cold exposure more livid bluish and more reddish at warmer temperatures. The patient was otherwise healthy and did not use any medication. She also had no previous history of allergies. Her last journeyoutsideofGermanywas to theKosovo, approximately 14 months before onset of skin symptoms. Topical treatment of the skin lesions with potent corticosteroid cream did not lead to any improvement and systemic penicillin treatment had no effect on the skin lesions.