Tanya is a 42-year-old lawyer who presents with firm, painful nodules over her fingertips and elbows that have gradually enlarged over several months. 

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<p>TANYA is a 42-year-old lawyer who presents with firm, painful nodules over her fingertips and elbows (pictured) that have gradually enlarged over several months. Some have ulcerated, discharging a chalky-white material.</p><p>Tanya also reports new-onset Raynaud’s phenomenon and that her fingers feel oddly tight and stiff.</p><p>She recently self-commenced esomeprazole for reflux but takes no other medications.</p><p>She denies arthralgia or systemic symptoms and has no past history of note.</p><p>Examination reveals the pictured finding in addition to sclerodactyly and multiple telangiectasias.</p><p>Laboratory investigations demonstrate positive antinuclear and anticentromere antibodies.</p><p>Rheumatoid factor, anticyclic citrullinated peptide and double-stranded DNA antibodies are normal, as are serum calcium, phosphate, uric acid and cholesterol levels.</p>

Dr Kate Kelso is a GP and medical editor at Australian Doctor.