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Enlarged wrists, ankles and feet were also noted, along with facial seborrhoea, Alpelisib cell line thickening of the skin and deformity of the fingers. He did not know of any history of similar conditions in family members. Physical examination of the scalp showed a cerebriform appearance with accentuating folds and deep furrows (cutis verticis gyrata), thickening in the face, frontal and parietal region (figure 1). Hyperkeratosis, palmoplantar hyperhidrosis and pachydermia of both hands with clubbing were also observed (figure 2). Swelling was observed in both knees (figure 3) with signs of joint effusion. Bone enlargement of the hands, knees, ankles and feet was also found. Figure?1 Deep facial skin folds around the nose, mouth and on the forehead. Cerebroid folds on the scalp. Figure?2 Clubbing and pachydermia of the hand. Figure?3 Bilateral knee swelling. Investigations The radiograph of the hands and feet reported periosteal thickening in the tubular aspect of the metatarsals, femur and metacarpals (figures 4?4?�C7). The skin biopsy of the frontal region demonstrated elongated epithelial cones with increased collagen fibre content, which are the cutis verticis gyrate features described in PDP. Routine laboratory tests including thyroid function tests, adrenocorticotropic hormone, cortisol, prolactin, rheumatoid factor, thoracoabdominal CT scan and arthrocentesis were normal. The diagnosis of PDP was made. Figure?4 Metatarsals with periosteal thickening. Figure?5 Bilateral diaphyseal expansion of tubular bones in the lower limbs. Figure?6 Outlining expansion of bilateral femurs without affecting the interarticular space. Figure?7 Phalangeal and metacarpal widening. Differential diagnosis Acromegaly. Outcome and follow-up The patient was treated with a keratolytic agent and non-steroidal anti-inflammatory drugs (NSAID) and referred to outpatient monitoring; however, he did not comply with the hospital. Discussion Primary hypertrophic osteoarthropathy (HOA) (PDP) is a rare syndrome characterised by finger clubbing, periosteal new bone formation especially over the distal ends of long bones and coarsening of the facial features.2 First reported cases were the Hagner brothers, who had typical features of this syndrome. They were first described by Friedreich in 1868. It was only 45?years ago that PDP was first recognised as a distinct entity by Touraine, Solente and Gole (1935).1 3 HOA is divided into primary and secondary forms. PDP, the primary form, accounts for 3�C5% of all cases of HOA. Secondary HOA, also called pulmonary HOA, is associated with underlying cardiopulmonary diseases and malignancies.1 Clinically, it is characterised by digital clubbing (89% of cases), pachydermia: thickening and wrinkling of facial features including the forehead and the nasolabial folds, with profound hypertrophy of the eyelids (30�C40% of cases) and cutis verticis gyrata (24% of cases).