Boy with lipstick-a clinical dilemma.

A 9-year-old boy presented with 2-year history of progressive discoloration of the lips and fingernails. The boy was a product of a nonconsanguineous marriage and was born at term with normal developmental milestones. There was no history of discoloration of any other areas, jaundice, breathlessness, easy fatigue, squatting spells or recurrent chest infections. The parents complained that the boy was always teased by the fellow students for applying lipstick (Figure 1). They denied any similar complaints by family members. The patient gave a history of dryness of the eyes since the age of 3 years and use