We report of a 23-year-old woman who presented with a six-month history of a recurring, pruritic rash located on her chest, upper abdomen and most recently on the lower back. Until then the patient had been healthy. She did not take any medications, was not aware of any allergies or a family his-tory of skin diseases.The rash had occurred initially six months ago and was marked by an acute onset and a chronic recurrent course. The patient noted a timely association between the onset of the skin lesions and the start of a vegetarian diet. Further-more physical activity and sweating worsened the symptoms.Clinically the woman presented with erythematous patches and urticarial papules as well as crusted vesicles and pustules with an erythematous base that were located on the chest and the inframammary folds and distributed in a symmetrical fashion (Figure 1A, B). Under the provisional diagnosis of an autoimmune bullous disease, the woman had recently received systemic and topical corticosteroids. Lesions progressed under this therapy. Additionally, new pink, slightly urticarial papules and plaques developed on the back. Intense pruritus was the main complaint of the patient. This symptom did not respond to antihistamine or steroid therapy.Routine laboratory tests including blood count, blood chemistry, and serum protein levels were normal. No ele-vated antinuclear antibody titers were found. Direct and indirect immunofluorescence assays and an ELISA to rule out an autoimmune bullous disease were performed and were negative.A skin biopsy taken from one of the most recent lesions on the back showed a sparse perivascular lymphocytic cell infiltrate with occasional neutrophils and a discrete edema of the papillary dermis (Figure 2). No epidermal changes were present. In contrast to these subtle changes, a skin biopsy taken from a fully developed inframammary lesion displayed dramatic epidermal changes consisting of ballooning of kera -tinocytes, necrosis en masse of keratinocytes with intraepi-dermal vesiculation and exocytosis of neutrophils and eosin -ophils. The epidermal changes were accompanied by a dense superficial interstitial and perivascular dermal inflammatory cell infiltrate consisting of lymphocytes mainly, but also neu -trophils and eosinophils (Figures 3, 4).The clinical and histopathologic findings summoned up to the diagnosis of prurigo pigmentosa. Alternative diagno-