Primary hyperoxalurias are rare autosomal recessive metabolic disorders associated with overproduction and tissue deposition of serum oxalate. Cutaneous findings relate to vascular deposition and include livedo reticularis, ulceration, and peripheral gangrene. In this case report, Blackmon et al describe a patient with end-stage renal disease and persistent acral sores and livedo of her extremities. Findings of physical examination suggested calciphylaxis or nephrogenic systemic fibrosis, but skin biopsy specimens revealed rectangular, birefringent crystalline material within the dermis, subcutis, and vessels. These findings and subsequent workup suggested primary hyperoxaluria, highlighting the importance of including this in the differential diagnosis in this setting.