Symmetrical brownish plaques on dorsum of hands

A man in his 40s presented with a four month history of dry, cracked, and hyperpigmented lesions on the dorsum of both hands (fig 1), which started as erythema and progressed to leathery hyperpigmented lesions. The lesions were associated with a burning sensation, which had become progressively worse over the previous three weeks. Similar lesions were not observed on other parts of the body. The patient gave a history of repeated episodes of abdominal pain and diarrhoea for the past year, for which he had not sought treatment. His diet consisted almost exclusively of maize and jowar (sorghum or Indian millet). For the past 20 years he had consumed about 15 g (about 2 units) of alcohol daily. He had no history suggestive of cognitive impairment, neuropsychiatric symptoms, or mood changes, and no other known medical or surgical comorbidities. Examination showed sharply demarcated hyperpigmented, scaly, cinnamon brown coloured plaques, symmetrically involving the dorsum of …