A 33-year-old male with no past medical history presented with itchy bumps on his legs, torso and arms, present for over 1 year. He had seen a primary care doctor the prior year, where he was diagnosed with folliculitis and given 2 weeks of oral antibiotics (he could not recall which one). He said the treatment made the whiteheads go away but that the bumps remained. The patient reported improvement in cooler weather and almost complete resolution in winter. With humid weather, the rash returned. He noted the rash got worse immediately after showering. Over the past few weeks, he’d noticed that each morning he was waking up with more lesions on his legs. He ran, played tennis, and surfed 2–3 times per week. He had been using over-the-counter hydrocortisone 1 % cream with little effect.

Vitals were normal. On exam, there were multiple 4–5 mm erythematous papules, some with pustules, scattered diffusely over the bilateral anterior lower extremities, and less diffusely on the posterior lower extremities . There were scattered 4–5 mm erythematous papules on the lower forearms and abdomen as well.

This appeared to be folliculitis. Given the severity, duration, and failure to resolve on 2 weeks of oral antibiotics , the patient was referred to dermatology for further evaluation.