More serious conditions must be ruled out
The differential for painless nodules includes cutaneous lymphoma and atypical infections of fungal or mycobacterial etiology.
Cutaneous lymphoma that manifests with leg tumors includes primary cutaneous anaplastic CD30+ large cell lymphoma (PCALCL) and primary cutaneous diffuse large B-cell lymphoma, leg type (PCDLBL-LT). The former may occur in young patients, whereas the latter tends to manifest in the elderly. Biopsy shows a neoplastic proliferation of atypical lymphocytes within the dermis,6 differing from our case.
Atypical infections may be detected through bacterial, mycobacterial, or fungal cultures, and may be accompanied by elevated inflammatory markers or other systemic symptoms of the infection, setting it apart from pretibial myxedema.
Treatment is simple and noninvasive
Pretibial myxedema is usually asymptomatic, with minimal morbidity. The nodular variant may resolve spontaneously; thus, therapeutic management often is reserved for severe cases or for those with cosmetic concerns. Treatment options include mid- to high-potency topical corticosteroids with an occlusive dressing for 1 to 2 weeks (or until resolution) or an intralesional triamcinolone injection (5-10 mg/mL, single or monthly until resolution), compression stockings, and pneumatic compression.2
This patient was treated with a single intralesional injection of triamcinolone 10 mg/mL. The nodules resolved within a month.