Immunosuppression is necessary in a large number of conditions to modify immune responses and control disease severity. It is a vital part of treatment regimes following organ and bone marrow transplants. However, the use of immunosuppressive drugs has been shown to cause infections with common and unusual pathogens. We present the case of a 5-year-old female heart transplant recipient. Nine months after the transplant, she developed a tender acneiform eruption on her face consisting of numerous small yellowish to pink papules and pustules. Many of the lesions had a central, firm, small spinulous excrescence or a central dell. Histopathology demonstrated abnormal maturation of the hair follicles, nucleated eosinophilic cells with trichohyalin granules. The clinical presentation and histological features were in keeping with trichodysplasia spinulosa, a rare complication in immunosuppressed subjects. Treatment trials included reduction of immunosuppression combined with topical and oral retinoids, topical acyclovir, and oral valganciclovir with limited success.