Intended for healthcare professionals

Endgames Spot Diagnosis

A lichenoid rash with hepatic origins

BMJ 2021; 372 doi: (Published 21 January 2021) Cite this as: BMJ 2021;372:m4976
  1. Leila Nemazee, dermatology specialist registrar,
  2. Janice Ferguson, dermatology consultant
  1. Dermatology Department, Salford Royal NHS Foundation Trust, Manchester, UK
  1. Correspondence to: L Nemazee leila.nemazee{at}

A woman in her 70s presented with a widespread rash of three months’ duration. The rash had started on her arms and spread to the trunk and legs. She described severe itching and a burning sensation. She also had non-specific symptoms of heartburn, weight loss, and loss of appetite for a similar period.

On examination, her limbs and trunk had an extensive grey-brown rash with a hint of purple, composed of small papules and excoriated, lichenified (thickened and leathery) plaques (fig 1). She had no mucosal involvement.

Fig 1

Grey-purple excoriated papules and plaques on upper back, and post-inflammatory pigmentation

Investigations showed a marginally raised alkaline …

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