Fig. 2

Follow up photographs of described skin changes over time. a Skin changes 5 weeks after first course of pulsed methyprednisolone and maintained on prednisolone 60 mg od. b 3 weeks after (a) and as steroid wean attempted, purpuric changes progressed to distal portions of other toes. Prednisolone re-escalated to 60 mg and slower weaning regime commenced. c, d 6 weeks after (b) slowly progressing necrosis and dry gangrene prompting second course of pulsed methylprednisolone and prostacyclin