Photo Quiz

Concurrent Painless Weeping Nodule and Targetoid Lesion on the Hand


Am Fam Physician. 2017 Dec 1;96(11):739-741.

A healthy 17-year-old presented with a one-week history of slowly progressing, painless skin lesions on the dorsum of the hand and the index finger. Approximately three weeks before the lesions appeared, he received a minor laceration on his hand while skinning slaughtered sheep at a farm. No topical medications had been applied to the lesions. The patient had no constitutional symptoms or other lesions.

Physical examination revealed an 8-mm, weeping nodule with surrounding induration and erythema on the left dorsal hand. A lesion on the index finger had an erythematous center with circumscribed hypopigmentation within a surrounding area of erythema (Figure 1).

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Figure 1.

Figure 1.


Based on the patient's history and physical examination findings, which one of the following is the most likely diagnosis?

A. Contagious ecthyma (orf).

B. Cutaneous anthrax.

C. Mycobacterium marinum infection.

D. Nocardia infection.

E. Sporothrix schenckii infection.


The answer is A: contagious ecthyma (orf), which is caused by a parapoxvirus. It is primarily transmitted from infected sheep or goats through direct contact or contaminated fomites. Orf is typically an occupational skin disease, but household exposures can occur with animal slaughtering or religious animal sacrifices. There have also been cases of children contracting orf after visiting petting zoos and livestock fairs.1,2 Hands are the most common site of infection and clinical presentation.

In immunocompetent patients, there are six distinct stages of orf 2,3: (1) three to seven days after inoculation, a painless erythematous macule appears and progresses into a papule (maculopapular stage); (2) the lesion develops a red center with a surrounding white ring and a red halo (targetoid stage), as depicted in Figure 1; (3) a weeping nodule

Address correspondence to Andy Chern, MD, MPH, at Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


show all references

1. Centers for Disease Control and Prevention. Human orf virus infection from household exposures—United States, 2009–2011. MMWR Morb Mortal Wkly Rep. 2012;61(14):245–248....

2. Leavell UW Jr, McNamara MJ, Muelling R, Talbert WM, Rucker RC, Dalton AJ. Orf. Report of 19 human cases with clinical and pathological observations. JAMA. 1968;204(8):657–664.

3. Al-Qattan MM. Orf infection of the hand. J Hand Surg Am. 2011;36(11):1855–1858.

4. Bolognia JL, Jorizzo J, eds. Dermatology. 3rd ed. Philadelphia, Pa.: Elsevier; 2012.

5. Uzel M, Sasmaz S, Bakaris S, et al. A viral infection of the hand commonly seen after the feast of sacrifice: human orf (orf of the hand). Epidemiol Infect. 2005;133(4):653–657.

6. Erbagci Z, Erbagci I, Almila Tuncel A. Rapid improvement of human orf (ecthyma contagiosum) with topical imiquimod cream: report of four complicated cases. J Dermatolog Treat. 2005;16(5–6):353–356.

7. Gluckman SJ. Mycobacterium marinum. Clin Dermatol. 1995;13(3):273–276.

8. Goldsmith LA, Fitzpatrick TB, eds. Fitzpatrick's Dermatology in General Medicine. 8th ed. New York, NY: McGraw-Hill; 2012.

9. Barros MB, de Almeida Paes R, Schubach AO. Sporothrix schenckii and sporotrichosis. Clinical Microbiol Rev. 2011;24(4):633–654.

This series is coordinated by John E. Delzell Jr., MD, MSPH, Assistant Medical Editor.

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