<s>[INST] Just did a routine check and ESR is 40 and i have patches all over my skin and hyperpigmentation on my face and neck. Please what can be the cause Just did a routine check and ESR is 40 and i have patches all over my skin and hyperpigmentation on my face and neck. Please what can be the cause [/INST] Hello joy;welcome to Chat Doctor The increased ESR can be a sign of many things like all sort of active infection in body;anemia;tuberculosis;fever etc., so it needs to be seen due to what you have it. If there is no infection, or you do not suffer any problem may be anemia can be the reason. Hyperpigmentation of skin is due to exposure to sun and also age related and should not have any relation with the increased ESR. Thanks </s>