Tumid lupus erythematosus

Medical condition

Tumid lupus erythematosus

Other names| "Lupus erythematosus tumidus"[1]
Specialty| Dermatology

Tumid lupus erythematosus is a rare, but distinctive entity in which patients present with edematous erythematous plaque.[2]

Lupus erythematosus tumidus (LET) was reported by Henri Gougerot and Burnier R. in 1930. It is a photosensitive skin disorder, a different subtype of cutaneous lupus erythematosus (CLE) from discoid lupus erythematosus (DLE) or subacute CLE (SCLE).[3] LET is usually found on sun-exposed areas of the body. Skin lesions are edematous, urticarialike annular papules and plaques. Topical corticosteroids are not effective as treatment for LET, but many will respond to chloroquine. LET resolves with normal skin, no residual scarring, no hyperpigmentation or hypopigmentation. Cigarette smokers who have LET may not respond very well to chloroquine.[4][5]

It has been suggested that it is equivalent to Jessner lymphocytic infiltrate of the skin.[6]

## Signs and symptoms

[edit]

The characteristic presentation of tumid lupus erythematosus is erythematous, edematous plaques that lack ulceration or scaling.[4] In contrast to discoid lupus erythematosus (DLE), there is no atrophy, scarring, or follicular plugging. Skin exposed to the elements, such as the face, upper chest (V-neck distribution), upper back, extensor arms, and shoulders, is typically affected by tumid lupus erythematosus.[7] Rare cases of tumid lupus erythematosus affecting the lower extremities have been documented, nevertheless.[8] Tumid lupus erythematosus typically manifests itself in the summer in temperate climates.[7]

Papules and plaques of tumid lupus erythematosus can create an annular pattern in certain patients, resembling annular subacute cutaneous lupus erythematosus (SCLE), with less edema at the center. A Blaschkoid distribution,[9][10] scalp involvement resembling alopecia areata,[11] and periorbital edema are less frequent signs of tumid lupus erythematosus.[12]

## Causes

[edit]

There is currently no known unique etiology for tumid lupus erythematosus. However, it has been shown that triggering variables like ultraviolet (UV) exposure can exacerbate tumid lupus erythematosus lesions.[13] Its link to autoimmune disease has generated debate; an autoimmune workup may be started if an autoimmune disease is suspected.[14][15] It is suggested that immune dysregulation results in T cell suppression.[16] There has been evidence of a correlation between smoking and medications such as thiazide diuretics, monoclonal antibodies, angiotensin-converting enzyme inhibitors, tumor necrosis factor antagonists, and highly active antiretroviral therapy.[17][18]

## Diagnosis

[edit]

The identification of consistent clinical symptoms and histopathologic findings is the basis for the diagnosis of tumid lupus erythematosus. Provocative phototesting results and antimalarial medication response are additional tests that are not usually required but can confirm a diagnosis of tumid lupus erythematosus.[7]

Proposed diagnostic criteria reflect key findings in tumid lupus erythematosus:[4]

1. Clinical \- Smooth-surfaced, succulent, urticarial-like, erythematous plaques in sun-exposed areas.[4]
2. Histologic \- There is no epidermal involvement or modification of the dermoepidermal interface; instead, there is perivascular and periadnexal lymphocytic infiltration, interstitial mucin deposition, and, in certain instances, dispersed neutrophils.[4]
3. Phototesting \- Skin lesion proliferation following exposure to ultraviolet A (UVA) and/or ultraviolet B (UVB) radiation.[4]
4. Treatment \- Quick and efficient systemic antimalarial medication treatment.[4]

## Treatment

[edit]

First-line treatments include photoprotection, topical calcineurin inhibitors, and intralesional and/or topical corticosteroids. Antimalarial medications like hydroxychloroquine or chloroquine should be used as part of a systemic treatment for patients who do not respond to conservative therapy or who have a severe illness. Methotrexate or mycophenolate mofetil along with folic acid supplements are examples of second-line therapy.[19] If all previous treatments are ineffective, third-line treatments such as thalidomide or lenalidomide may be considered.[4][20] Another effective treatment for suppressive, non-curative conditions is pulse dye laser.[21] In order to keep the lesions from relapsing in these patients, trigger avoidance measures including wearing sunscreen and abstaining from smoking are essential.[19]

## See also

[edit]

* Lupus erythematosus
* List of cutaneous conditions

## References

[edit]

1. ^ Rapini, Ronald P.; Bolognia, Jean L.; Jorizzo, Joseph L. (2007). Dermatology: 2-Volume Set. St. Louis: Mosby. ISBN 978-1-4160-2999-1.
2. ^ James, William; Berger, Timothy; Elston, Dirk (2005). Andrews' Diseases of the Skin: Clinical Dermatology. (10th ed.). Saunders. Page 159. ISBN 0-7216-2921-0.
3. ^ Gougerot H, Burnier R. Lupus érythémateux "tumidus". Bull Soc Fr Dermatol Syphiligr. 1930;37:1291-1292.
4. ^ a b c d e f g h Kuhn, Annegret; Richter-Hintz, Dagmar; Oslislo, Claudia; Ruzicka, Thomas; Megahed, Mosaad; Lehmann, Percy (2000-08-01). "Lupus Erythematosus Tumidus". Archives of Dermatology. 136 (8). American Medical Association (AMA): 1033–1041\. doi:10.1001/archderm.136.8.1033. ISSN 0003-987X. PMID 10926740.1033-1041&rft.date=2000-08-01&rft.issn=0003-987X&rft_id=info:pmid/10926740&rft_id=info:doi/10.1001/archderm.136.8.1033&rft.aulast=Kuhn&rft.aufirst=Annegret&rft.au=Richter-Hintz,+Dagmar&rft.au=Oslislo,+Claudia&rft.au=Ruzicka,+Thomas&rft.au=Megahed,+Mosaad&rft.au=Lehmann,+Percy&rfr_id=info:sid/en.wikipedia.org:Tumid+lupus+erythematosus" class="Z3988">
5. ^ Callen, Jeffrey P. (2002). "Management of skin disease in patients with lupus erythematosus". Best Practice & Research Clinical Rheumatology. 16 (2). Elsevier BV: 245–264\. doi:10.1053/berh.2001.0224. ISSN 1521-6942. PMID 12041952.245-264&rft.date=2002&rft.issn=1521-6942&rft_id=info:pmid/12041952&rft_id=info:doi/10.1053/berh.2001.0224&rft.aulast=Callen&rft.aufirst=Jeffrey+P.&rfr_id=info:sid/en.wikipedia.org:Tumid+lupus+erythematosus" class="Z3988">
6. ^ "Jessner Lymphocytic Infiltration of the Skin: eMedicine Dermatology". Retrieved 2010-05-22.
7. ^ a b c "UpToDate". UpToDate. Retrieved 2024-03-02.
8. ^ Stead, Jennifer; Headley, Catherine; Ioffreda, Michael; Kovarik, Carrie; Werth, Victoria (2008). "Coexistence of Tumid Lupus Erythematosus With Systemic Lupus Erythematosus and Discoid Lupus Erythematosus". JCR: Journal of Clinical Rheumatology. 14 (6). Ovid Technologies (Wolters Kluwer Health): 338–341\. doi:10.1097/rhu.0b013e31817d1183. ISSN 1076-1608. PMC 2829660. PMID 18664992.338-341&rft.date=2008&rft_id=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2829660#id-name=PMC&rft.issn=1076-1608&rft_id=info:pmid/18664992&rft_id=info:doi/10.1097/rhu.0b013e31817d1183&rft.aulast=Stead&rft.aufirst=Jennifer&rft.au=Headley,+Catherine&rft.au=Ioffreda,+Michael&rft.au=Kovarik,+Carrie&rft.au=Werth,+Victoria&rft_id=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2829660&rfr_id=info:sid/en.wikipedia.org:Tumid+lupus+erythematosus" class="Z3988">
9. ^ Pacheco, T R; Spates, S T; Lee, L A (2002). "Unilateral tumid lupus erythematosus". Lupus. 11 (6). SAGE Publications: 388–391\. doi:10.1191/0961203302lu208cr. ISSN 0961-2033. PMID 12139378. S2CID 35133682.388-391&rft.date=2002&rft.issn=0961-2033&rft_id=https://api.semanticscholar.org/CorpusID:35133682#id-name=S2CID&rft_id=info:pmid/12139378&rft_id=info:doi/10.1191/0961203302lu208cr&rft.aulast=Pacheco&rft.aufirst=T+R&rft.au=Spates,+S+T&rft.au=Lee,+L+A&rfr_id=info:sid/en.wikipedia.org:Tumid+lupus+erythematosus" class="Z3988">
10. ^ Hinz, Torsten; Hornung, Thorsten; Wenzel, Joerg; Bieber, Thomas (2012-03-27). "Lupus tumidus following the lines of Blaschko". International Journal of Dermatology. 52 (12). Wiley: 1615–1617\. doi:10.1111/j.1365-4632.2011.05419.x. ISSN 0011-9059. PMID 22458246. S2CID 27225913.1615-1617&rft.date=2012-03-27&rft.issn=0011-9059&rft_id=https://api.semanticscholar.org/CorpusID:27225913#id-name=S2CID&rft_id=info:pmid/22458246&rft_id=info:doi/10.1111/j.1365-4632.2011.05419.x&rft.aulast=Hinz&rft.aufirst=Torsten&rft.au=Hornung,+Thorsten&rft.au=Wenzel,+Joerg&rft.au=Bieber,+Thomas&rfr_id=info:sid/en.wikipedia.org:Tumid+lupus+erythematosus" class="Z3988">
11. ^ Werth, Victoria P. (1992-03-01). "Incidence of Alopecia Areata in Lupus Erythematosus". Archives of Dermatology. 128 (3): 368. doi:10.1001/archderm.1992.01680130082010. ISSN 0003-987X. PMID 1550369.
12. ^ Vassallo, Camilla; Colombo, Giovanni; Canevari, Frank Rikki; Brazzelli, Valeria; Ardigò, Marco; Carrera, Carlo; Cananzi, Raffaello; Borroni, Giovanni (2005-04-14). "Monolateral severe eyelid erythema and edema as unique manifestation of lupus tumidus". International Journal of Dermatology. 44 (10). Wiley: 858–860\. doi:10.1111/j.1365-4632.2005.02210.x. ISSN 0011-9059. PMID 16207190. S2CID 45610534.858-860&rft.date=2005-04-14&rft.issn=0011-9059&rft_id=https://api.semanticscholar.org/CorpusID:45610534#id-name=S2CID&rft_id=info:pmid/16207190&rft_id=info:doi/10.1111/j.1365-4632.2005.02210.x&rft.aulast=Vassallo&rft.aufirst=Camilla&rft.au=Colombo,+Giovanni&rft.au=Canevari,+Frank+Rikki&rft.au=Brazzelli,+Valeria&rft.au=Ardigò,+Marco&rft.au=Carrera,+Carlo&rft.au=Cananzi,+Raffaello&rft.au=Borroni,+Giovanni&rfr_id=info:sid/en.wikipedia.org:Tumid+lupus+erythematosus" class="Z3988">
13. ^ Saleh, Dahlia; Grubbs, Hailey; Koritala, Thoyaja; Crane, Jonathan S. (2023-06-28). "Tumid Lupus Erythematosus". StatPearls Publishing. PMID 29494121. Retrieved 2024-03-02.
14. ^ Jefferson, Gina D.; Aakalu, Vinay K.; Braniecki, Marylee (2017). "Tumid lupus: An unexpected diagnosis for the otolaryngologist". American Journal of Otolaryngology. 38 (2). Elsevier BV: 257–259\. doi:10.1016/j.amjoto.2017.01.003. ISSN 0196-0709. PMC 5826658. PMID 28122678.257-259&rft.date=2017&rft_id=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5826658#id-name=PMC&rft.issn=0196-0709&rft_id=info:pmid/28122678&rft_id=info:doi/10.1016/j.amjoto.2017.01.003&rft.aulast=Jefferson&rft.aufirst=Gina+D.&rft.au=Aakalu,+Vinay+K.&rft.au=Braniecki,+Marylee&rft_id=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5826658&rfr_id=info:sid/en.wikipedia.org:Tumid+lupus+erythematosus" class="Z3988">
15. ^ Fogagnolo, L.; Soares, T. C. B.; Senna, C. G.; Souza, E. M.; Blotta, M. H. S. L.; Cintra, M. L. (2014-09-12). "Cytotoxic granules in distinct subsets of cutaneous lupus erythematosus". Clinical and Experimental Dermatology. 39 (7). Oxford University Press (OUP): 835–839\. doi:10.1111/ced.12428. ISSN 0307-6938. PMID 25214407. S2CID 21127920.835-839&rft.date=2014-09-12&rft.issn=0307-6938&rft_id=https://api.semanticscholar.org/CorpusID:21127920#id-name=S2CID&rft_id=info:pmid/25214407&rft_id=info:doi/10.1111/ced.12428&rft.aulast=Fogagnolo&rft.aufirst=L.&rft.au=Soares,+T.+C.+B.&rft.au=Senna,+C.+G.&rft.au=Souza,+E.+M.&rft.au=Blotta,+M.+H.+S.+L.&rft.au=Cintra,+M.+L.&rfr_id=info:sid/en.wikipedia.org:Tumid+lupus+erythematosus" class="Z3988">
16. ^ Gambichler, T.; Pätzholz, J.; Schmitz, L.; Lahner, N.; Kreuter, A. (2015-03-25). "<scp>FOXP</scp>3+ and <scp>CD</scp>39+ regulatory T cells in subtypes of cutaneous lupus erythematosus". Journal of the European Academy of Dermatology and Venereology. 29 (10). Wiley: 1972–1977\. doi:10.1111/jdv.13123. ISSN 0926-9959. PMID 25808110. S2CID 30625226.1972-1977&rft.date=2015-03-25&rft.issn=0926-9959&rft_id=https://api.semanticscholar.org/CorpusID:30625226#id-name=S2CID&rft_id=info:pmid/25808110&rft_id=info:doi/10.1111/jdv.13123&rft.aulast=Gambichler&rft.aufirst=T.&rft.au=Pätzholz,+J.&rft.au=Schmitz,+L.&rft.au=Lahner,+N.&rft.au=Kreuter,+A.&rfr_id=info:sid/en.wikipedia.org:Tumid+lupus+erythematosus" class="Z3988">
17. ^ Böckle, B C; Sepp, N T (2014-11-19). "Smoking is highly associated with discoid lupus erythematosus and lupus erythematosus tumidus: analysis of 405 patients". Lupus. 24 (7). SAGE Publications: 669–674\. doi:10.1177/0961203314559630. ISSN 0961-2033. PMID 25411260. S2CID 43483915.669-674&rft.date=2014-11-19&rft.issn=0961-2033&rft_id=https://api.semanticscholar.org/CorpusID:43483915#id-name=S2CID&rft_id=info:pmid/25411260&rft_id=info:doi/10.1177/0961203314559630&rft.aulast=Böckle&rft.aufirst=B+C&rft.au=Sepp,+N+T&rfr_id=info:sid/en.wikipedia.org:Tumid+lupus+erythematosus" class="Z3988">
18. ^ Schneider, Stefan W.; Staender, Sonja; Schlüter, Bernhard; Luger, Thomas A.; Bonsmann, Gisela (2006-01-01). "Infliximab-Induced Lupus Erythematosus Tumidus in a Patient With Rheumatoid Arthritis". Archives of Dermatology. 142 (1). American Medical Association (AMA): 115–116\. doi:10.1001/archderm.142.1.115. ISSN 0003-987X. PMID 16415403.115-116&rft.date=2006-01-01&rft.issn=0003-987X&rft_id=info:pmid/16415403&rft_id=info:doi/10.1001/archderm.142.1.115&rft.aulast=Schneider&rft.aufirst=Stefan+W.&rft.au=Staender,+Sonja&rft.au=Schlüter,+Bernhard&rft.au=Luger,+Thomas+A.&rft.au=Bonsmann,+Gisela&rfr_id=info:sid/en.wikipedia.org:Tumid+lupus+erythematosus" class="Z3988">
19. ^ a b Liu, Evan; Daze, Robert P; Moon, Summer (2020-05-26). "Tumid Lupus Erythematosus: A Rare and Distinctive Variant of Cutaneous Lupus Erythematosus Masquerading as Urticarial Vasculitis". Cureus. Springer Science and Business Media LLC. doi:10.7759/cureus.8305. ISSN 2168-8184. PMC 7320659. PMID 32607289.
20. ^ Gallitano, Stephanie M.; Haskin, Alessandra (2016). "Lupus erythematosus tumidus: A case and discussion of a rare entity in black patients". JAAD Case Reports. 2 (6). Elsevier BV: 488–490\. doi:10.1016/j.jdcr.2016.05.022. ISSN 2352-5126. PMC 5149049. PMID 27981226.488-490&rft.date=2016&rft_id=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5149049#id-name=PMC&rft.issn=2352-5126&rft_id=info:pmid/27981226&rft_id=info:doi/10.1016/j.jdcr.2016.05.022&rft.aulast=Gallitano&rft.aufirst=Stephanie+M.&rft.au=Haskin,+Alessandra&rft_id=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5149049&rfr_id=info:sid/en.wikipedia.org:Tumid+lupus+erythematosus" class="Z3988">
21. ^ Truchuelo, M.T.; Boixeda, P.; Alcántara, J.; Moreno, C.; de las Heras, E.; Olasolo, P.J. (2012). "Pulsed dye laser as an excellent choice of treatment for lupus tumidus: a prospective study". Journal of the European Academy of Dermatology and Venereology. 26 (10): 1272–1279\. doi:10.1111/j.1468-3083.2011.04281.x. ISSN 0926-9959. PMID 21957901.1272-1279&rft.date=2012&rft.issn=0926-9959&rft_id=info:pmid/21957901&rft_id=info:doi/10.1111/j.1468-3083.2011.04281.x&rft.aulast=Truchuelo&rft.aufirst=M.T.&rft.au=Boixeda,+P.&rft.au=Alcántara,+J.&rft.au=Moreno,+C.&rft.au=de+las+Heras,+E.&rft.au=Olasolo,+P.J.&rfr_id=info:sid/en.wikipedia.org:Tumid+lupus+erythematosus" class="Z3988">

## Further reading

[edit]

* Schmitt, V.; Meuth, A.M.; Amler, S.; Kuehn, E.; Haust, M.; Messer, G.; Bekou, V.; Sauerland, C.; Metze, D.; Köpcke, W.; Bonsmann, G.; Kuhn, A. (2009-07-07). "Lupus erythematosus tumidus is a separate subtype of cutaneous lupus erythematosus". British Journal of Dermatology. 162 (1). Oxford University Press (OUP): 64–73\. doi:10.1111/j.1365-2133.2009.09401.x. ISSN 0007-0963. PMID 19712116. S2CID 23655462.64-73&rft.date=2009-07-07&rft.issn=0007-0963&rft_id=https://api.semanticscholar.org/CorpusID:23655462#id-name=S2CID&rft_id=info:pmid/19712116&rft_id=info:doi/10.1111/j.1365-2133.2009.09401.x&rft.aulast=Schmitt&rft.aufirst=V.&rft.au=Meuth,+A.M.&rft.au=Amler,+S.&rft.au=Kuehn,+E.&rft.au=Haust,+M.&rft.au=Messer,+G.&rft.au=Bekou,+V.&rft.au=Sauerland,+C.&rft.au=Metze,+D.&rft.au=Köpcke,+W.&rft.au=Bonsmann,+G.&rft.au=Kuhn,+A.&rfr_id=info:sid/en.wikipedia.org:Tumid+lupus+erythematosus" class="Z3988">
* Vieira, Vanessa; Del Pozo, Jesús; Yebra-Pimentel, Maria Teresa; Martínez, Walter; Fonseca, Eduardo (2005-01-06). "Lupus erythematosus tumidus: a series of 26 cases". International Journal of Dermatology. 45 (5). Wiley: 512–517\. doi:10.1111/j.1365-4632.2004.02574.x. ISSN 0011-9059. PMID 16700782. S2CID 43363996.512-517&rft.date=2005-01-06&rft.issn=0011-9059&rft_id=https://api.semanticscholar.org/CorpusID:43363996#id-name=S2CID&rft_id=info:pmid/16700782&rft_id=info:doi/10.1111/j.1365-4632.2004.02574.x&rft.aulast=Vieira&rft.aufirst=Vanessa&rft.au=Del+Pozo,+Jesús&rft.au=Yebra-Pimentel,+Maria+Teresa&rft.au=Martínez,+Walter&rft.au=Fonseca,+Eduardo&rfr_id=info:sid/en.wikipedia.org:Tumid+lupus+erythematosus" class="Z3988">

## External links

[edit]

* VisualDx
* Healthgrades

Classification|

* ICD-11: EB51.Y
* ICD-10: L93.2
* SNOMED CT: 200941006

|

External resources|

* GARD: Lupus erythematosus tumidus
* Orphanet: 90283
* Scholia: Q3267714

* v
* t
* e

Cutaneous keratosis, ulcer, atrophy, and necrobiosis

Epidermal thickening|

* keratoderma: Keratoderma climactericum
* Paraneoplastic keratoderma
* Acrokeratosis paraneoplastica of Bazex
* Aquagenic keratoderma
* Drug-induced keratoderma
* psoriasis
* Keratoderma blennorrhagicum

* keratosis: Seborrheic keratosis
* Clonal seborrheic keratosis
* Common seborrheic keratosis
* Irritated seborrheic keratosis
* Seborrheic keratosis with squamous atypia
* Reticulated seborrheic keratosis
* Dermatosis papulosa nigra
* Keratosis punctata of the palmar creases

* other hyperkeratosis: Acanthosis nigricans
* Confluent and reticulated papillomatosis
* Callus
* Ichthyosis acquisita
* Arsenical keratosis
* Chronic scar keratosis
* Hyperkeratosis lenticularis perstans
* Hydrocarbon keratosis
* Hyperkeratosis of the nipple and areola
* Inverted follicular keratosis
* Lichenoid keratosis
* Multiple minute digitate hyperkeratosis
* PUVA keratosis
* Reactional keratosis
* Stucco keratosis
* Thermal keratosis
* Viral keratosis
* Warty dyskeratoma
* Waxy keratosis of childhood

* other hypertrophy: Keloid
* Hypertrophic scar
* Cutis verticis gyrata

Necrobiosis/granuloma|

| Necrobiotic/palisading|

* Granuloma annulare
* Perforating
* Generalized
* Subcutaneous
* Granuloma annulare in HIV disease
* Localized granuloma annulare
* Patch-type granuloma annulare
* Necrobiosis lipoidica
* Annular elastolytic giant-cell granuloma
* Granuloma multiforme
* Necrobiotic xanthogranuloma
* Palisaded neutrophilic and granulomatous dermatitis
* Rheumatoid nodulosis
* Interstitial granulomatous dermatitis/Interstitial granulomatous drug reaction

|

Foreign body granuloma|

* Beryllium granuloma
* Mercury granuloma
* Silica granuloma
* Silicone granuloma
* Zirconium granuloma
* Soot tattoo
* Tattoo
* Carbon stain

Other/ungrouped|

* eosinophilic dermatosis
* Granuloma faciale

Dermis/
localized CTD|

| Cutaneous lupus
erythematosus|

* chronic: Discoid
* Panniculitis

* subacute: Neonatal

* ungrouped: Chilblain
* Lupus erythematosus–lichen planus overlap syndrome
* Tumid
* Verrucous
* Rowell's syndrome

|

Scleroderma/
Morphea|

* Localized scleroderma
* Localized morphea
* Morphea–lichen sclerosus et atrophicus overlap
* Generalized morphea
* Atrophoderma of Pasini and Pierini
* Pansclerotic morphea
* Morphea profunda
* Linear scleroderma

Atrophic/
atrophoderma|

* Lichen sclerosus
* Anetoderma
* Schweninger–Buzzi anetoderma
* Jadassohn–Pellizzari anetoderma
* Atrophoderma of Pasini and Pierini
* Acrodermatitis chronica atrophicans
* Semicircular lipoatrophy
* Follicular atrophoderma
* Linear atrophoderma of Moulin
* Atrophia maculosa varioliformis cutis

Perforating|

* Kyrle disease
* Reactive perforating collagenosis
* Elastosis perforans serpiginosa
* Perforating folliculitis
* Acquired perforating dermatosis

Skin ulcer|

* Pyoderma gangrenosum

Other|

* Calcinosis cutis
* Sclerodactyly
* Poikiloderma vasculare atrophicans
* Ainhum/Pseudo-ainhum

*[v]: View this template
*[t]: Discuss this template
*[e]: Edit this template