A man in his 40s with mixed African American and white race/ethnicity, Fitzpatrick skin type IV, and history of pulmonary sarcoidosis and secondary pulmonary aspergillomas presented for a follow-up dermatologic examination. Unremarkable findings from a skin examination had been noted 3 years previously. The patient returned for dermatologic examination and was noted to have new hyperpigmented lesions on his forearms that were present for a few months. At the time, the patient had been receiving voriconazole, 200 mg twice daily, for 32 months for treatment of his fungal disease. In addition, the patient had a history of long-term prednisone use (varying doses of up to 60 mg/d) since 2008 to manage his pulmonary sarcoidosis. Because of progressively deteriorating pulmonary function and intermittent, worsening hemoptysis, an evaluation for lung transplant was initiated.