A 79-year-old woman presented from a nursing home with unusual lower extremity skin changes. Her medical history included congestive heart failure, morbid obesity, chronic lymphedema, and deep vein thrombosis with inferior vena cava filter placement. There was no history of cellulitis, filariasis, or travel to endemic areas. The patient was afebrile without adenopathy and had bilateral lower extremity edema with hyperpigmented, cobble-stoned, hyperkeratotic skin and verrucous nodules on the inner thighs (Figures 1 and2). Elephantiasis nostras verrucosa secondary to longstanding lymphedema and obesity was diagnosed by the dermatology consultant. The patient was treated with compression stockings and topical emollients. Elephantiasis nostras verrucosa is a rare disorder secondary to chronic noninfectious or recurrent cellulitic lymphedema that results in hyperplastic fibrotic dermal changes. 1 Diagnosis is clinical, but biopsy to exclude malignancies such as Stewart-Treves syndrome is needed in atypical cases. 2 Treatment options include compression stockings, limb elevation, topical keratolytics, emollients, retinoids, and surgical debridement. 2,3