
Am Fam Physician. 2025;111(6):547-548
Author disclosure: No relevant financial relationships.
A 44-year-old woman presented with pruritic hand lesions that had been present for several years. There was no associated discharge, bleeding, or pain. The patient had used nail clippers to make the nodules smaller, but they had gradually enlarged. She did not have a history of arthritis, local trauma, or application of topical agents to the affected areas.
The patient had a history of fibroadenoma of the right breast, obesity, osteoarthritis, temporomandibular joint disorder, varicose veins of the lower extremity, and vitamin D deficiency. She was a janitor and wore nitrile gloves at work. She had no relevant family history.
Physical examination of the skin revealed raised, hypopigmented, nontender nodules on the proximal interphalangeal and metacarpophalangeal joints of her left hand (Figure 1). The lesions were slightly pink but had no associated erythema.

QUESTION
Based on the patient's history and physical examination, which one of the following is the most likely diagnosis?
A. Gouty tophi.
B. Knuckle pads.
C. Nodular osteoarthritis.
D. Rheumatoid nodules.
E. Xanthomas.
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