A 38-year-old woman presented with a 4-month history of progressive itchy dome-shaped nodules on the extensor surfaces of her arms and hands (Fig 1). She had a 20-year history of type 1 diabetes and had commenced hemodialysis therapy for end-stage diabetic nephropathy 1 year prior to presentation. Her medical history included depression, gastroesophageal reflux, and hypertension. Her regular medications were bisoprolol, epoetin beta, amitriptyline, paracetamol, omeprazole, and insulin. She lived with her son, was unemployed, and smoked 20 cigarettes per day.