A 35-year-old man presented with an eruption that dated to his late 20s. The rash consisted of itchy, hyperpigmented macules and papules, most of which measured less than 1 cm. For many years, he sought no care and only recently visited a physician to discuss his condition. The "itchy spots" on the patient's skin were fewer in number and less symptomatic during the summer, when he spent a great deal of time outdoors, sailing. Although the rash was pruritic, he did not notice any other systemic symptoms.
Specifically, he denied a headache, flushing, abdominal pain, palpitations, or syncope and was otherwise in excellent health. Upon physical examination, the patient had red-brown, macular, and slightly papular lesions on his lateral face, neck, chest, back, and upper extremities. Nevi were present in the background but were not the principal feature. Fewer lesions were present on the…
