A 59-year-old African American female presented with a one-year history of progressive skin darkening. Her only symptom was mild itching. Medications included diltiazem 180 mg daily (extended release), prescribed three years earlier. Examination revealed blue-gray reticular hyperpigmentation in a photodistributed pattern on the face, neck, “V of the chest,” and extensor forearms (Fig. 1a, b). Punch biopsy showed a predominantly lichenoid reaction with upper dermal melanophages.
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