LAUSR

A woman in her 20s with a history of severe plaque psoriasis presented with painful bumps on her lower legs. She had no history of similar lesions. Her medications included cyclosporine, hydroxyzine, and topical steroids (clobetasol, triamcinolone, and desonide). Of note, she had no history or current use of antibiotics or oral contraceptives. Physical examination revealed tender, erythematous, nonulcerated nodules on the bilateral shins. These lesions did not radiate or appear elsewhere on the body, and no other abnormal skin findings were present. Moreover, the patient generally appeared to be well, and lymphadenopathy was absent. A diagnostic punch biopsy was performed, and the histopathology results showed a dense neutrophilic infiltrate and negative staining for bacteria, fungi, and mycobacteria. The lesions self-resolved soon thereafter, and further work-up was deferred. Adalimumab therapy was then initiated to treat her psoriasis. Over the following year, the patient’s psoriasis initially improved on adalimumab 40 mg every other week, but after several exacerbations, the dose frequency was increased to every week. Her psoriasis responded and remained stable on this dosing, but the tender nodules on her shins continued to recur and selfresolve every few months. During this time, the patient denied any fever, malaise, gastrointestinal symptoms, respiratory symptoms, or menstruation changes. She further denied any trauma to the shins, and QuantiFERON-TB Gold testing results were negative. The patient continued to appear well and report generally good overall health, and physical examination results remained within normal limits, with the exception of the recurring tender nodules on her shins. Given this history, no imaging was performed due to a lack of concern for systemic disease. Nearly 2 years after the first appearance of these lesions, the patient presented for routine follow-up and was found to have new psoriatic plaques directly overlying the areas where her most recent tender nodules occurred (Fig. 1). These plaques are uniformly circular, mimicking the preceding tender nodules in that location. During this time, the patient had no modifications to