Head and lateral line erosion syndrome (HLLES) is a common but very poorly understood disease of marine aquarium fish. One suspected etiology is the use of granulated activated carbon (GAC) to filter the water. Seventy-two ocean surgeons Acanthurus bahianus were distributed among three carbon-negative control systems and three GAC-treated systems such that each tank contained approximately the same total body mass. Each replicate system was made up of two 250-L circular tanks with a common filtration system (6 fish per tank, 12 fish per replicate system). The GAC-treated tanks were exposed to full-stream, extruded coconut shell activated carbon, which produced a mean total organic carbon content of 0.4 mg/L. The results of this study indicate that extruded coconut shell activated carbon filtering at full-stream rates can cause HLLES-type lesions in ocean surgeons. The HLLES developed exponentially over 15 d, beginning in the chin region. This was followed by pitting in the cheek region, which expanded until erosions coalesced. Once the carbon was discontinued, the processes reversed in a mean time of 49 d. As the lesions healed, they reverted from the coalesced to the pitted stage and then darkened before returning to normal.