A 5-year-old girl with a 1-year history of a heart transplant, on immunosuppression with tacrolimus and mycophenolate mofetil and oral valganciclovir for cytomegalovirus prophylaxis, presented with a papular eruption on her face, trunk, and extremities. The lesions were first noted 7 months after her transplant and had spread. There was no associated pain, pruritus, or systemic symptoms such as fever, fatigue, night sweats, or weight loss. On physical examination, numerous hyperpigmented to skin-colored folliculocentric papules with central white keratotic projections were noted on her face, ears, trunk, and extremities, with increased concentration around the patient's nose (Figures 1 and 2). In addition to keratotic spicules, pink to skincolored papules with scale were noted on the patient's lower extremities (Figure 2). A punch biopsy was obtained from a lesion on the lower extremities (Figure 3).