Acral freckling with palmar pits

Figure 1: Reticulate freckle-like hyperpigmentation of the dorsa of hands Figure 2: Hyperpigmented macules in a reticular fashion over the extensor surface of forearms A 32-year-old female patient presented with asymptomatic hyperpigmentation of both the forearms and hands since 15 years. The pigmentation initially began over the hands and gradually extended to involve the forearms. Patient’s mother and sister also had similar complaints. Clinical examination revealed multiple hyperpigmented macules configured in a reticulate pattern involving the dorsal aspect of hands [Figure 1] and extensor aspects of both forearms [Figure 2]. Palmar aspects of both the hands had multiple fine pits [Figure 3]. Rest of the cutaneous examination was unremarkable. A 4 mm punch biopsy from the hyperpigmented region revealed slightly atrophic epidermis with an intensely melanized basal layer [Figure 4]. Based on the clinical and historical findings, a diagnosis of reticulate acropigmentation of Kitamura (RAK) was considered and confirmed by histopathological examination.