50 year-old female with hx of SLE presenting with excoriated papules and flushing

     

    This is a 50 yo F with a h/o SLE and depression who presented with a several year history of 5-15mm excoriated, erythematous papules on the upper extremities and chest.  Pt reports that the papules are often extremely itchy and worse in the summer.  Pt also admits to episodic flushing and joint pains, but denies any GI symptoms.  

    Records show a previous biopsy report consistent with prurigo nodularis and ?elevated urinary 5HIAA.  Medications include benlysta, cellcept, diuretics and psychiatric medications.