This 42-year-old man, who was a heavy smoker with a 2 year history of Raynaud phenomenon, developed ischemic ulcers covered with black eschars on the tips of his fingers and toes. The lesions progressed to dry gangrene of the distal phalanges of the index, middle and ring fingers of his left hand and all of the toes of his left foot. He was treated with broad sprectrum anbiotics, advised to stop smoking immediately, and sent for surgical consultation. Buerger disease (thromboangiitis obliterans) is a nonatherosclerotic, segmental, inflammatory, vasoocclusive disease affecting the small and medium sized arteries and veins of the upper and lower extremities. This disorder is strongly associated with heavy tobacco use, and progression of the disease is closely linked to continued smoking.