We report a 59-year-old woman with a background history of CREST syndrome (calcinosis, Raynaud phenomenon, (o)esophageal dysmotility, sclerodactyly and telangiectasia) and secondary pulmonary hypertension who presented with a bilateral lower limb vasculitic rash.

A couple of weeks earlier she had been initiated on nebulised iloprost (Ventavis; Bayer New Zealand, Auckland, New Zealand) for progression of her pulmonary hypertension while on treatment with Sildenafil. She started on 20 μg three times a day, increasing every 3 days to a total of 20 μg every 4 h. Within a few days of reaching the maximum dose she developed a painful vasculitic rash over both lower limbs, which did not respond to analgesia and …