Finger pebbles (FP) is a skin thickness occurring most frequently on the dorsum of the fingers and characterized by micropapules or "pebbles." This condition usually occurs in patients with diabetes mellitus. Here we report the first case of pickwickian syndrome with vanishing FP on the dorsal side of the hands, elbows, and knees in a patient with extreme obesity, moderate insulin resistance, normal glucose tolerance test results, and severe hypoxemia. The FP rapidly regressed with body weight loss, suggesting a link with obesity. However, the patient also had pickwickian syndrome with severe hypoxemia. So, we believe that both hyperinsulinemia and hypoxemia could have played a role in causing this case of FP.