A 48-year-old man presented to the dermatology clinic with a 6-month history of painful hand ulcerations and shortness of breath. He has no muscle weakness or arthritis. What is the diagnosis?

CREST syndrome17%  

Anti-MDA5 dermatomyositis34%  

Pyoderma gangrenosum16%  

Cutaneous polyarteritis nodosa19%  

Behcet’s disease13%  

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https://www.nejm.org/image-challenge?ci=20190725&query=TOC