A 61-year-old man presented with a one-year history of skin changes in acral regions and nail changes affecting both hands. His overall health and nutritional status were otherwise good. In the past year, his symptoms had worsened despite treatment with isosorbide dinitrate ointment and mometasone cream. There was an incidental fi nding of chronic nicotine abuse (40 pack years) as well as grade II hemorrhoids. The patient had no fever, night sweats, weight loss, fatigue, pain, or loss of appetite. There were no dermatological disorders in the patient's own or family history. Clinical appearancesThe results of the clinical examination revealed acral erythema with pityriasis-like scaling on the fi ngertips, the tip of the nose, and the helices. Nail changes were identifi ed on both hands and feet, consisting of onychodystrophy, subungual hyperkeratosis, and onycholysis (Figure 1, 2). Palpation of the lymph nodes did not reveal any abnormalities. The remainder of the skin as well as the visible mucous membranes also appeared normal. Histological analysisThe epithelium was hyperkeratotic with normal stratifi cation and parakeratosis. Subepidermal appearances included

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