A 68-year-old man presented to the rheumatology clinic with a 5-year history of skin changes on his chest and back. He was a current smoker and had been hospitalized 3 months earlier because of shortness of breath. Evaluation at that time had included computed tomography of the chest, which revealed findings consistent with fibrotic and emphysematous changes in the lower lobes of both lungs, as well as transthoracic echocardiography, which was notable for an elevated pulmonary artery systolic pressure. At the current visit, physical examination showed clubbing of the fingers; crackles in both lung bases; “salt-and-pepper” skin changes on the chest and back, characterized by hypopigmentation and hyperpigmentation in areas of sclerotic skin; and diffuse skin thickening that extended down each arm to a point proximal to the elbows. Testing for antitopoisomerase I (anti–Scl-70) antibodies was positive. A diagnosis of diffuse cutaneous systemic sclerosis was made. Immunosuppressive therapy was initiated; 3 months later, partial regression of the skin thickening and salt-and-pepper changes was noted, and the patient reported less shortness of breath.