Facial cystic lesions and onychodystrophy

A 7-year-old Caucasian girl was referred to our dermatology department because of multiple small cystic lesions that were present since birth. They were predominantly located in the frontal region and in both armpits. Her growth and development were normal, although her parents reported a history of natal teeth and axillary bromhydrosis, without any other associated systemic symptoms. Physical examination revealed multiple small, yellowish, cystic lesions located over the entire frontal region, lower eyelids, and bilateral axillary region (Figure 1). She had a painful nodular, erythematous lesion in her right armpit (Figure 2). Examination of the fingernails and toenails revealed thickening and deformity, distal subungual hyperkeratosis, and yellowish chromonychia (Figure 3). She had nonpainful mild keratoderma on her heels. She had straight blonde hair; findings from electron microscopy examination of the hair are shown in Figure 4. Her eyelashes and eyebrows were normal. The rest of the physical examination was normal, including mucous membranes. No other family members were affected.