A 4-year-old boy born in Jamaica presented to the emergency department with a 2-year history of intermittent “rash.” His mother described red scaly patches affecting only the palms of his hands and the soles of his feet, and he was brought in for evaluation secondary to an acute increase in itching and pain. The patient had been scratching the lesions to the point of skin breakdown, and he had been less inclined to bear weight on his feet secondary to pain. The family had been using topical over-the-counter hydrocortisone acetate cream and oral antihistamines without significant effect. They noted periods when the skin lesions improved but no period of true skin clearing over the past 2 years. He had no recent fevers, weight loss, joint pain, dental issues, or mucous membrane lesions. There was no family history of any dermatologic condition. Results of his physical examination revealed diffuse erythema with scaly yellow-brown plaques on the volar aspects of the hands and the plantar aspects of the feet (Figures 1 and 2). There were areas of fissuring with minimal bleeding. The remainder of the cutaneous examination was remarkable only for a small white scaly patch on his chest and for his having dystrophic fingernails and toenails with some evidence of pitting. His hair and teeth were normal.