For several years, a 63-year-old African-American woman’s facial lesions have been slowly growing. Although they are largely asymptomatic, the patient is quite unhappy with their appearance. Additionally, she has developed respiratory symptoms of cough and shortness of breath—the latter unresponsive to antibiotics, inhalers, and a course of prednisolone.

Her primary care provider (PCP) orders a chest x-ray and a tuberculin skin test, but neither offers any diagnostic clues. The PCP tries topical steroids (0.1% triamcinolone) and metronidazole creams for the lesions, but these are of no help. The patient is then referred to dermatology for evaluation and treatment.

Examination reveals at least 3 separate pink plaques on the patient’s face. The largest, on the left medial cheek, measures 4 × 2 cm. The 2 others, located on the mid-vermillion surfaces of the upper and lower lips, are both about 1.8 cm and round.

The plaques are soft, devoid of scales or other surface disruptions, and nontender to palpation. There is no growth of follicular orifices on the surfaces of the lesions. No adenopathy is detectable in the area.

The patient appears to be in reasonably good health. She is in no distress, but she coughs frequently during her clinic visit.