For about 3 years, dozens of lesions have been growing in size and prominence in the middle of this 8-year-old girl’s face. Under the presumption that they represent acne, she was treated for that condition, with no benefit. At a loss, her primary care provider refers her to dermatology.

The patient has a history of seizures—beginning early in life—that are under decent management. There is no family history of similar problems, nor of any related disease.

She has been having behavioral problems at school, where she is a year behind her peers. Some of her counselors have suggested she has autism spectrum disorder—a suggestion with which her family strongly disagrees. The patient’s behavior in clinic is well within normal limits, as is her general appearance.

EXAMINATION

Distributed in a butterfly-like pattern, the facial lesions cover the middle portion of her face and nose. Each of the 1-to-2-mm papules is identical: firm, round, and pink; none are pustular. There are no comedones on her face.

Further examination reveals 2 to 4 hypopigmented macules scattered around her trunk. On her upper back, there is a solitary, pink, polygonal plaque covered with fine, soft papules. On her trunk, there are 4 café-au-lait macules, each ranging from 1 to 3 cm; none are seen on her axillae. Her nails and teeth are free of notable lesions or changes.