Clinical manifestation

Cutaneous findings: symmetrical areas of involvement including dorsal surfaces of hands, face, neck (Casal necklace), arms, and feet

Early skin changes: edematous, exudative plaques, evolving to erythema on dorsa of hands, with pruritus and burning sensation; erythema sometimes evolves to cinnamon brown in color; coalescent bullae in some patients; dry brown scales and crusts, resulting from hemorrhage, scale, and erythema on sun-exposed skin Late skin changes: darkly pigmented, thickened, dry, scaly, hard, rough, and cracked skin; glossitis with soreness of the mouth Gastrointestinal findings: poor appetite; nausea; vomiting; diarrhea; epigastric discomfort; abdominal pain; increased salivation

Neuropsychiatric changes: headache, irritability; poor concentration; anxiety; delusional state; hallucinations; stupor; apathy; tremor; ataxia; spastic paresis

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