Acral and periorificial scaly erythematous plaques in a child

A 7 year old girl presented with a six year history of pruritic erythema on her face and extremities. She had been breastfed after birth, introduced to solid foods gradually, and completely weaned at 1 year of age. Symptoms began after weaning. Eczema and atopic dermatitis were repeatedly diagnosed, but symptoms did not improve with use of oral antihistamines, topical corticosteroids, and emollients. The patient also experienced diffuse hair thinning, intermittent diarrhoea, and lack of energy. There were no developmental concerns. The patient had no additional symptoms and no relevant medical history, but a younger brother had similar albeit milder symptoms. On examination, scaly erythematous plaques were observed predominantly involving the fingers and toes, inner canthus and perioral, perinasal, and perianal areas (fig 1). Results of …