Hyperpigmented nodular rash in a 61-year-old African American female

A 61-year-old African American female presents to an outpatient family health center with a hyperpigmented nodular rash of 2 months’ duration. The rash first appeared on her abdomen before spreading across her upper arms, lower leg, back, face and scalp. She has a history of controlled type 2 diabetes mellitus, cerebral aneurysm rupture, Sjögren’s syndrome, asthma and a left below-the-knee amputation due to osteomyelitis. She smokes cigarettes but does not use alcohol or illicit substances. She has also noticed a dry cough with mild dyspnea on exertion over the past 6 months. On physical exam, hyperpigmented nodules are palpable in both the intradermal and subcutaneous layers of the skin. Nodules are firm, mobile and nontender. Alopecia is noted where scalp nodules are present. Her lungs exhibit diminished air movement throughout, with scattered, end-expiratory wheezing.