What Caused These Bluish Bumps?

A 16-year-old man was brought to the dermatology clinic by his father for evaluation of several small bluish “bumps” that he first noticed at least 6 months prior on his left wrist (Figure 1). Since then, he had developed similar lesions on his left heel and right calf (Figures 2 and 3). Some of the lesions seem to have grown, and those on the wrist were occasionally tender, especially with activity or exercise. He denied any recent trauma to the areas, although he reported poking his skin with pencils several years prior to presentation. However, he denied poking his skin in the areas of these lesions. The patient had a history of Asperger syndrome and oppositional defiance disorder; he took no medications. He denied ever being on minocycline. Physical examination was notable for a cluster of 2- to 4-mm nontender, nonblanching, blue/purple macules on the volar left wrist, which appeared distinct from the underlying vessels. Two 3 mm similar lesions were present on the right calf, and one 4-mm lesion was present on the lateral left heel. The patient denied any gastrointestinal symptoms. No other family members had similar lesions. A punch biopsy was performed on one of the lesions on the right calf.

What is your diagnosis?

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