Viola is a 71-year-old Caucasian woman who presents to her GP for a routine iron infusion for recurrent iron deficiency.

At review prior to the procedure, Viola’s GP incidentally notices a rash on the proximal interphalangeal joints of the fourth and fifth digits of her right hand (see figure 1).

The erythematous rash has been present for six months and has a scaly appearance. It is non-tender, and self-treatment with OTC steroid cream has yielded no improvement. 

No other systemic symptoms are present. Vitals signs are within normal limits, she has normal heart sounds, her chest is clear and there are no abnormalities on gastrointestinal and CNS examinations.