This is a case of nephrogenic systemic fibrosis (NSF) or also called nephrogenic fibrosing dermopathy. It is similar in appearance microscopically and on clinical examination to scleromyxdema and it is typically associated with gadolinium exposure to patients with renal insufficiency. It typically manifest with thickening and brawny hyperpigmentation and sometimes might be associated with subcutaneous nodules. Although most cases have been reported in dialytic and renal transplant populations it can also occur in dialysis naive patients. Click here to learn more about NSF on Medscape.