A legally blind woman in her late 70s had refused medical care for over 10 years when her family brought her for evaluation of lesions on her legs (A and B). She was diagnosed with a goiter at 16 and underwent radioiodine ablation treatment in her 30s for Graves’ disease. On presentation, she had a heart rate of 44 with normal temperature and blood pressure. She exhibited mild exophthalmos and clubbing (C). Her legs were enlarged from below the midshins with thickened, non-pitting plaques. There were multiple non-tender, non-pruritic nodules around the ankles and the dorsal aspects of the feet, sparing the plantar surfaces. Laboratory evaluation revealed a white blood count of 2.5 k/?L and a TSH of 21.53 mcIU/mL. A punch biopsy of a nodule showed epidermal atrophy with marked dermal edema and vascular congestion with hemorrhage. X-ray imaging of her hands (D) revealed periosteal proliferation of the shafts of the phalanges (example: arrow). The diagnosis of thyroid dermopathy and acropachy was made based on the combination of clinical, laboratory, and radiological data. The patient was started on thyroid replacement therapy along with compression therapy for the lower extremities, resulting in minimal improvement in the lower extremity nodules.