Photo Derm Diagnosis: Swelling of small joints and multiple ulcers near metacarpophalangeal joints

A male patient, aged 55-year, presented with swelling of small joints of both hands with skin ulceration near the metacarpophalangeal joints (Figure 1). The skin lesions had started as firm skin colored papules which were painless about 6 months back. Papules ulcerated about a month back and hands and forearms were extremely itchy. Patient had lost 4 kilograms of weight in 1 year and had a past history of tuberculosis 2 years back. He was suffering from low grade fever for the last 3 months.