What's producing this patchy pattern?

A nine-year-old Caucasian girl presents with four weeks of brown patches over the lateral and dorsal aspects of her dominant left hand and wrist.

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Professor Dedee Murrell is head of the department of dermatology at St George Hospital, Sydney, and conjoint professor at the University of NSW.

This article is co-authored by Joslin Johal, a medical student at the University of NSW, and Dr Timothy Cowan, a dermatology registrar at St George Hospital.