Photo Quiz

Papular Lesions on Bilateral Elbows and Knees


Am Fam Physician. 2019 Jan 1;99(1):47-48.

A 41-year-old man presented with foot pain, which had been present for three months. He also had lesions on his elbows and knees that had been present for about five years. The patient's history included tobacco use, newly diagnosed hypertension, and a recent transient ischemic attack. Before the transient ischemic attack, he was not seeing a physician regularly.

Physical examination revealed nontender, red-yellow papules scattered across the extensor surfaces of the elbows and knees (Figure 1 and Figure 2). They were approximately 3 mm to 1 cm in size.

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

A. Gouty tophi.

B. Granulomatosis with polyangiitis.

C. Rheumatoid nodules.

D. Sarcoidosis.

E. Xanthomas.


The answer is E: xanthomas. Xanthomas are nontender lesions consisting of abnormal lipid deposition and foam cells.1 They are characterized by accumulations of lipid-laden macrophages and can develop in the setting of altered lipid metabolism, although they occasionally occur without underlying metabolic effects.1,2 Xanthomas do not represent a disease; rather, they are a sign of a variety of lipoprotein disorders.1 One major clinical feature of xanthomas is the yellow to red hue. Morphology can vary from macules and papules to plaques and nodules.3 They can develop on the skin and tendons.

Xanthomas are classified into four categories: eruptive, planar, tendinous, and tuberoeruptive or tuberous. Eruptive xanthomas are yellow-red papules that appear suddenly in crops on extensor surfaces of the extremities and the buttocks. Planar xanthomas are yellow macules, papules, or plaques on the upper eyelids, wrists, palms, and intertriginous areas. Tendinous xanthomas are firm nodules

Author disclosure: No relevant financial affiliations.

Address correspondence to Tracy Persily, DO, at Reprints are not available from the authors.


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

2. Torres KM. Xanthomas. March 25, 2015. Medscape. Accessed April 25, 2018.

3. Massengale WT. Xanthomas In: Bolognia JL, Cerroni L, Schaffer JV, eds. Dermatology 4th ed. Philadelphia, Pa: Elsevier; 2018.

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

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