A 69-year-old woman presented for the evaluation of a slowly progressive, asymptomatic cutaneous eruption on her hands and forearms, as well as an enlarging, painful ulcer on her left leg that developed 6 months earlier. Her medical history was notable for essential thrombocytosis, which had been complicated by portal vein thrombosis, and she had been receiving treatment with hydroxyurea and rivaroxaban for the past 2 years. Despite worsening cutaneous disease, she otherwise felt well and denied associated fevers, weakness, weight loss, myalgias, arthralgias, or other constitutional symptoms.