He was not taking any medications, denied allergies, and was a nonsmoker. Recommended vaccinations were up to date. During the first week of cycling, the patient reported redness and swelling of his fingers, worse after

evening rewarming. Small tender nodules also began to appear bilaterally. By nightfall on day 12, the lesions had increased in size and progressed to form blisters. An associated intense burning itch required medication with 25 mg of promethazine to allow sleep. On day 17, the patient cycled over a 2,550 m snow-capped peak. That evening, the lesions had progressed in number and size, and the itch increased in intensity. At this point, the patient noted raised red lesions developing on both earlobes and nose. Severity of symptoms peaked on day 18. That evening, the patient Akt inhibitor required assistance in campsite activities involving fine motor skills. On examination

check details on day 18, there were more than 30 erythematous maculopapular lesions, many vesicular. The lesions were almost exclusively located between metacarpophalangeal joints and distal interphalangeal joints. The lesions were round, averaging 5–12 mm in diameter. Digital edema was present, affecting the nailbeds, and there was no evidence of synovitis (Figure 1). Notably, the thumbs were spared. The earlobes and nose were affected with slightly raised erythematous plaques. The patient did not describe any constitutional symptoms, denied symptoms of Raynaud’s phenomenon, and had an unremarkable basic physical examination with no other features indicating a systemic connective tissue disorder. Over the following week the symptoms gradually improved as the ambient temperature rose across the country. After 3 weeks there was complete resolution of the lesions. Upon his return to Australia, the patient received a rheumatology consultation. Serological markers of an autoimmune disorder were unremarkable: erythrocyte sedimentation rate (ESR) 2 mm/h [reference range (RR) 2–10]; antinuclear antibodies (ANA) mid-body titer 1:40, rheumatoid factor <20.0 IU/mL (RR: <20); extractable nuclear

antibodies were negative and anti-double-stranded DNA 2.3 IU/mL (RR: 0–4.0). Progesterone Based on history, examination, serology, and serial photographs of the above-described lesions, a diagnosis of primary perniosis was made. Prevention with nifidepine was recommended during future trips into cold environments. Although being described in hikers and soldiers, this is the first reported case of perniosis in a touring cyclist.1,4 Perniosis is a clinical diagnosis, made when a patient has the defined lesions temporally associated with cold.1,3 It is categorized as either primary or secondary to an autoimmune process. In the latter, perniosis may coexist with a systemic disease or manifest as the initial presentation of a systemic illness.1,2 Once a diagnosis is established, recent literature supports screening for an autoimmune cause.