Acral lesions with an underlying internal malignancy

A 58-year-old Hispanic woman with cholangiocarcinoma of the common bile duct resected 1 year before consultation (Fig 1) presented with a 1-month history of bilateral, asymptomatic, fissured, hyperkeratotic purple-red plaques on her first and second fingers and xanthonychia and onycholysis of all fingernails (Fig 2). There was no significant irritant or allergen exposure. Clobetasol propionate 0.05% with occlusion once daily and emollients had no effect. Lesions spread toward the fifth finger and dorsal surfaces of her hands.

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