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Lesions on arms/legs

We are very worried about our son. He has seen numerous doctors including 2 dermatologists and none are able to identify what is happening with him.
He has had lesions (red marks) on his arms occurring and reoccurring for the last 7 months. Occurring once a month until the last month and a half when they have started occurring every few days. Painful an hour or two before showing on the skin, then they appear and then for the next few hours to 24 hours they are painful feeling like pinching (lighter red) and burning (darker red). Then they start to fade away and will be completely gone within 2-5 days from when they first appeared. For the first time a few also started appearing on both legs this past week. They are like a bruise but disappears quicker and when pressed doesn't hurt any worse but, he feels less feeling where the red marks are compared to touching a different part of the skin. Tylenol and cold packs help very little with the pain.

Description: Never itchy. They are painful when first appearing until they start to fade which is usually a few hours after appearing to a day or so later that they start to fade away. Then the red marks (lesions) will be gone completely from the skin within 2-5 days. Comes frequently every few days a new occurrence but, disappears frequently also. Smooth on skin like a bruise, not raised on skin or bumpy. No fever or any other symptoms besides some stomach pain with gas when eating but, this may be a separate issue since it started 2 months ago when we were traveling in India. At the time of the lesions occurring we hadn't traveled anywhere in the previous 9 months. Before that he had been to Canada and we frequently visit India.

See pictures in profile.
A lot of bloodwork was done and all came back normal.
Biopsy results and photos are uploaded.

We need help identifying these lesions.
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1318109 tn?1292888573
Welcome to the Dermatology Expert Forum! Thank you for presenting information in such a systematic way.

We reviewed photographs, pathohistological report and your post. Based on all provided, first diagnosis on our differential diagnosis list is Purpura Annularis Telangioctodes (Majocchi Purpura). However, histology does not correlate completely with clinical diagnosis and it might be useful to perform another biopsy on a representative, untreated lesion old less than 24 hours. Also, detailed medical history should be taken. Exposure to different drugs and contact allergens should be investigated and those eliminated if detected. Purpura Annularis Telangioctodes is a benign disorder, can last for months with remissions and relapses. Treatment strategy has to be discussed with your dermatologists.

Other forms of pigmented purpuric dermatoses have to be taken into account (as differential diagnoses) as well as possibility that these lesions are just an early phase of a different disease. That is also why repeated biopsy of a new, fresh lesion could help.

We hope this information helps as an educational input. Please keep us posted on new developments.

Wishing Your Son and You Optimal Health,
Dr. Jasmina Jankicevic
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