A 70-year-old Asian female presented to the rheumatology clinic with a 5-year history of tender papules on fingers and toes aggravated under cold exposure. She also reported polyarthralgia and Raynaud phenomenon for 3 years. On examination, red painful papules were present on index fingers, middle fingers, thumbs, and toes, with central crust and ulceration (Fig. 1A-D). The toenail plates were partially or completely destroyed with hyperkeratosis of the nail bed (Fig. 1D). The extremities were cool to the touch.
