Previously undiagnosed Darier disease complicated by bilateral ecthyma gangrenosum masquerading as a vasculopathy with retiform eschar formation

We present the case of a 57-year-old incarcerated man with a history of hepatitis C and life-long presumed atopic dermatitis who presented with a two month history of painful, progressive, ulcerations with overlying eschars on his bilateral lower extremities. He had been treated unsuccessfully with oral trimethoprim-sulfamethoxazole and clindamycin before admission. Upon admission, he was found to have leukocytosis but was otherwise hemodynamically stable and afebrile. On exam, he had erythematous hyperkeratotic papules coalescing into plaques on the neck, chest, abdomen, back, and extremities, with a flexural predominance, and retiform ulcerations with overlying eschars on the bilateral lower legs.