A 66-year-old man with hypertension presented in early summer with cellulitis of the legs and a 2-week history of a diffuse pruritic papular dermatitis. Treatment was begun with cephalexin, hydroxyzine hydrochloride, and 0.05% betamethasone dipropionate cream. After initial improvement, the dermatitis worsened, and within 10 days, marked fatigue, fever, chills, and toe pain developed.

Physical examination revealed disseminated hemorrhagic papules and extensive reticulated purpura with central areas of necrosis on the trunk, abdomen (Figure 1), scrotum, and extremities. Purpuric bullae were prominent on the distal aspect of the lower extremities (Figure 2). Reticulated erythema and purpura were present on the helixes and antihelixes of both ears and multiple toes. The blood pressure reading was 161/77 mmHg, the pulses were intact, and there was 2+ pitting edema of the ankles.