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Recurrent photosensitive burning rash and edema in a child

A 5yearold boy presented in the summer for a burning rash that recurred three times over the previous 4 months. In the most recent outbreak, he also reported anorexia and asthenia. Physical examination revealed petechiae on a background of diffuse erythema and edema, with few overlying erosions, symmetrically involving the nose, cheeks (Figure 1), extensor surface of the forearms, dorsal surface of hands, fingers (Figure 2), and feet. Fever, mucosal involvement, lymphadenopathy, or organomegaly were not found. Laboratory tests were remarkable for relative lymphocytosis with atypical lymphocytes, mild thrombocytopenia, slightly elevated transaminases, and positive anticytomegalovirus IgM and IgG. EpsteinBarr virus serology was negative. The diagnosis was assumed to be cytomegalovirus infection. However, the patient returned 1 year later with the same lesions, but no systemic symptoms. On further questioning, his mother and maternal grandmother reported similar cutaneous lesions, of milder severity, after sun exposure. A skin biopsy (Figure 3), and additional blood and urine tests were performed.