Scratching the surface - when skin lesions are more than they appear

A previously healthy 17-month-old boy was referred for pediatric consultation due to recurrent skin lesions.Five months earlier, he presented a pruritic vesicular rash in the thorax, abdomen and arm, which resolved spontaneously.Four months later, he developed a similar rash.For suspected herpes zoster infection, his family doctor started treatment with acyclovir without any improvement.At the time, there was no weight loss, restricted growth or gastrointestinal manifestations.There was also no history of autoimmune disease in the family.At the pediatric consultation, the child presented the skin lesions demonstrated in Image 1. His mother also reported diarrhea in the previous week, with no other associated symptoms.Blood tests were performed, including total IgA (69.3 mg/dL, normal rate 17-137 mg/dL), anti-tissue transglutaminase IgA (>128 U/mL), anti-gliadine IgG and IgA (188 U/mL, 142 U/mL) and anti-endomysium antibodies (1/320, normal rate < 1/10), which were positive.After discussing diagnostic pathways with the family, the patient underwent upper endoscopy with biopsies of the intestinal mucosa (bulb and distal duodenum) that presented atrophy of intestinal villi, crypt hyperplasia and inflammatory infiltrate, with type 3B Marsh-Oberhuber classification.The patient started a gluten-free diet with regression of the cutaneous manifestations and normalization of the antibodies.