A 73-year-old woman was attended for multiple crusted lesions on her head and hands for more than 1 year. These lesions had appeared 1 year ago as red patches with adherent scales without accompanying itch or pain. The patches gradually enlarged and proliferated with thick scales and an ulcer on the left side of her face. The patient suffered from polycythemia vera and had been treated with hydroxyurea (HU), 500 mg daily for 6 years. There was no personal history of local radiotherapy or heavy sun exposure and no family history of malignancy.On examination, several large infiltrated plaques with irregular borders were seen on the eyebrows, cheeks, jaw, nose and hands. The largest one was located on the left cheek (6 × 3 cm 2 ) (Figure 1a,b). A thick scale covered all lesions. In addition, there were smaller red plaques with fine scaling in sun-exposed areas (Figure 1a,b). Lab analyses including blood cell counts and serum chemistry were normal. A skin biopsy from the lesion on her left cheek was done (Figure 1b).