A punch biopsy specimen was obtained

A 62-year-old woman with a history of rosacea and melasma presented with worsening gray-brown patches on the face. One year prior to presentation, the patient had a facial rash characterized by redness, burning, and minimal pruritus. The rash subsequently improved but resulted in dark patches covering the forehead, cheeks, and neck. She intermittently continued to experience mild facial erythema. No oral or other cutaneous lesions were reported. She previously tried topical tacrolimus, triamcinolone, flurandrenolide, azelaic acid, intermittent hydroquinone, and glycolic acid peels. Other than asthma treatment, she denied any significant history of systemic medications.

Examination showed diffuse gray-brown mottled hyperpigmented patches at the forehead, cheeks, and neck, sparing the central face, with focal red, poorly demarcated patches at the medial cheeks and glabella. Close examination and dermoscopy showed blue-gray dots arranged in circles. A punch biopsy specimen was obtained.

You can read the whole presentation in JAMA Dermatology.