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Little white spots: An approach to hypopigmented macules
Abstract
Loss of pigment, either partial (hypopigmentation) or complete (depigmentation), can have a profound psychological impact, perhaps seemingly out of proportion for something that is almost exclusively benign.(1) Remarkably, hypopigmentation has been referenced in many ancient religious texts, often in the context of being a curse or contagious disease, firmly securing this cutaneous malady at the very deepest level of culture.(2) A compelling illustration of this occurs in the Old Testament when Miriam speaks against Moses and is punished thusly: "... suddenly Miriam became leprous, as white as snow."(3) It is difficult to imagine a more wicked association for a skin disease than such an execration. Although the vast majority of hypopigmentation encountered in the modern world is neither contagious nor dangerous, fear, anxiety and uncertainty continue to surround this problem for patient and physician alike. An exhaustive list of causes of hypopigmentation and depigmentation would contain many rare and obscure entities, but in this review the focus will be limited to three of the most common causes of acquired loss of pigment in children.(4) By closely examining pityriasis alba, pityriasis (tinea) versicolor, and vitiligo, some of the fear, anxiety and uncertainty may be dispelled and, even if they cannot be cured, simple understanding may provide some relief.
... Many skin diseases are accompanied by hypopigmentation or depigmentation. Vitiligo, pityriasis alba and pityriasis versicolor and varietas alba are seen in everyday clinical practice, and these diseases will be discussed (6). ...
... Th e diagnosis of vitiligo is set on the basis of history and the characteristic clinical picture, additional laboratory analysis are rarely needed, skin biopsy even rarer. In children there may be diff erential diagnostic diffi culties in relation to other diseases that are accompanied by hypopigmentation, such as pityriasis alba, pityriasis versicolor varietas alba, post-infl ammatory hypopigmentation, piebaldism, morfea, leprosy, tuberous sclerosis, naevus depigmentosus and lichen sclerosus et atrophicus (4,6). A special diffi culty for the recognition of vitiligo arises in fair-skinned people, where it is harder to spot hypopigmentation or depigmentation. ...
... Recent studies have indicated the frequent occurrence of PA in individuals who sunbathe without using photoprotection, and the onset of PA as a result of frequent sunbathing. In these patients the low levels of serum copper was detected, and it is known that copper plays an important role in the synthesis of tyrosinase, which may explain the hypopigmentation (6,48). ...
Th e loss of pigment, either partial (hypopigmentation) or complete(depigmentation), can have a major psychological impact on patients.Hypopigmentation disorders, congenital and acquired, are very numerous, and many of them are rarely seen. Th is paper provides anoverview of the most common hypopigmentation disorders in childrenand adolescents, stressing the importance of vitiligo and autoimmunedisorders in patients. Vitiligo is an acquired disease, possibly ofautoimmune nature, sometimes with a clear hereditary component,which is characterized by progressive, clearly defined, milky whitespots on the skin and/or mucous membranes. In about 50% of patientsvitiligo occurs before 20 years of age. Th e clinical picture of vitiligo in children and adolescents is similar to adults, but there are some differences in the epidemiology, their associations with other endocrine and/or autoimmune diseases and treatment of vitiligo in children compared to adult patients.
... The disease begins with an erythematous plaque with elevated edges, and desquamation occurs after several weeks. The changes are localized on the head, neck, and upper limbs [17]. ...
... Indeed, PA is considered a low-grade eczematous dermatitis and is regarded as a minor feature of atopic dermatitis and a personal or family history of atopy has been found in 85.5% of patients affected by PA (20) ,The results of Lio study found 19 out of 36 cases with PA were atopic. The previous study reported higher rates of atopy (17) but other reported lower rates of atopy (21) , Another researcher claimed that atopic dermatitis is probably more comorbidity of PA than an etiopathogenetic factor (20) . ...
... Lio (21) reported that pityriasis alba has been widely considered as a mild form of atopic dermatitis. It was found that the presence of skin manifestations of atopy was more common in pityriasis alba patients. ...
... The cause of PA is still unknown, but the condition is widely considered as a mild form of atopic dermatitis (5). Pityriasis alba disease in children are more influenced by socio-economic status, climatic exposure, dietary habits and external environment as compared to adults, cutaneous dermatoses are common in children during school going years (6), Poverty, malnutrition, overcrowding, poor hygiene, illiteracy and social, backwardness (7), helminthes (8), iron deficiency (9), soaps and Cutaneous xerosis (10). Recent studies have found direct relations between the incidence of PA disease and atopy, the amount of the sun exposure, the lack of sunscreen use, and frequency of bathing (11). ...
1935 ﺑﻨﺴﺒﺔ) 10.54 (% اﻟﻤﺼﺎﺑﯿﻦ اﻟﺬﻛﻮر وﻋﺪد ، 1067) 55.14 (% اﻹﻧﺎث وﻋﺪد 868) 44.86 (% ﺑﯿﻦ اﻟﻌﻤﺮﯾﺔ واﻟﻔﺌﺔ اﻹﻧﺎث ﻣﻦ أﻛﺜﺮ اﻟﺬﻛﻮر ﻋﻨﺪ اﻟﺒﯿﻀﺎء اﻟﻨﺨﺎﻟﯿﺔ ﺑﺪاء اﻹﺻﺎﺑﺔ ﻧﺴﺒﺔ و) 6 – 8 (أﻛﺜﺮ ﺳﻨﺔ اﻟﻌﻤ اﻟﻔﺌﺎت ﻣﻦ ﻟﻺﺻﺎﺑﺔ ً ﺗﻌﺮﺿﺎ اﻟﻔﺌﺎت ﻣﻦ اﻟﺴﻤﺮاء اﻟﺒﺸﺮة ذوي اﻷطﻔﺎل ﻋﻨﺪ ً وﺿﻮﺣﺎ أﻛﺜﺮ اﻟﺒﯿﻀﺎء اﻟﺒﻘﻊ إن وﺗﺒﯿﻦ ﻛﻤﺎ ،اﻷﺧﺮى ﺮﯾﺔ ﻣﻦ ﯾﻌﺎﻧﻮن اﻟﻠﺬﯾﻦ اﻟﻤﺼﺎﺑﯿﻦ ﻋﺪد وان ،اﻷﺧﺮى اﻟﺠﺴﻢ أﺟﺰاء ﺑﻘﯿﺔ ﻣﻦ أﻛﺜﺮ اﻟﻮﺟﮫ ﻓﻲ اﻟﺒﻘﻊ ظﮭﻮر أن وﻟﻮﺣﻆ ،اﻟﺒﯿﻀﺎء أﻟﺒﺸﺮة ذوي اﻷطﻔﺎل اﻟﺪم ﻓﻘﺮ 232 ﺑﻨﺴﺒﺔ اﻟﻤﺼﺎﺑﯿﻦ ﻣﻦ) 12 (% ، 242 ﺑﻨ ﺴﺒﺔ 12.5 % ،ﻻﻣﺒﯿﻠﯿﺎ اﻟﺠﯿﺎردﯾﺎ وطﻔﯿﻠﻲ ،اﻟﺪﺑﻮﺳﯿﺔ ﺑﺎﻟﺪﯾﺪان اﻹﺻﺎﺑﺔ ﻣﻦ ﯾﻌﺎﻧﻮن أﺧﺮى ﻣﻌﻮﯾﺔ طﻔﯿﻠﯿﺎت وﺟﻮد ﻋﻦ ﻓﻀﻼ ﻟﻠﻨﺴﯿﺞ اﻟﺤﺎﻟﺔ واﻻﻧﺘﯿﻤﯿﺒﺎ. اﻻﺳﺘﻨﺘﺎﺟﺎت : أﺟﺮﯾﺖ اﻟﺘﻲ اﻟﻤﺸﺎﺑﮭﺔ ﺑﺎﻟﺪراﺳﺎت ﻣﻘﺎرﻧﺔ ﻣﻘﺒﻮﻟﺔ ﻛﺎﻧﺖ اﻟﺒﯿﻀﺎء اﻟﻨﺨﺎﻟﯿﺔ ﺑﺪاء اﻹﺻﺎﺑﺔ ﻧﺴﺒﺔ ﺑﺎن ﺗﺒﯿﻦ اﻟﺪراﺳﺔ ھﺬه ﻓﻲ ﻋﺪة ﻓﻲ اﻹھﻤﺎل ﯾﻌﻜﺲ ذﻟﻚ و أﻗﻄﺎر ، اﻟﺸﺨﺼﯿﺔ اﻟﻌﻨﺎﯾﺔ ﻗﻠﺔ ، اﻟﺘﻐﺬﯾﺔ ﻧﻘﺺ ، اﻷوﻟﯿﺔ اﻟﺼﺤﯿﺔ اﻟﺮﻋﺎﯾﺔ وﻗﻠﺔ. اﻟﺘﻮﺻﯿﺎت : اﻟﺪراﺳﻲ اﻟﻌﺎم ﺑﺪاﯾﺔ ﻓﻲ اﻟﻄﺒﻲ اﻟﻔﺤﺺ ﺑﺈﺟﺮاء ﻧﻮﺻﻲ اﻟﺪراﺳﺔ ھﺬه ﻧﺘﺎﺋﺞ ﻋﻠﻰ ﺑﻨﺎءا ، ذات ﻟﻠﺘﻼﻣﯿﺬ اﻟﺪوري اﻟﻔﺤﺺ إﺟﺮاء أھﻤﯿﺔ. واﻵﺑﺎء ﻟﻠﻤﻌﻠﻤﯿﻦ اﻟﺼﺤﯿﺔ اﻟﺘﺮﺑﯿﺔ اﻟﺒﯿﺌﺔ ﻧﻈﺎﻓﺔ و اﻟﺸﺨﺼﯿﺔ اﻟﺼﺤﯿﺔ اﻟﻌﻨﺎﯾﺔ ﺣﻮل. اﻟﺒﺤﺚ ﻣﻔﺮدات : ﻧﺴﺒﺔ ﺗﺤﺪﯾﺪ ، اﻟﺒﯿﻀﺎء اﻟﻨﺨﺎﻟﯿﺔ ﻣﺮض ، اﻻﺑﺘﺪاﺋﯿﺔ اﻟﻤﺪارس ﺗﻼﻣﯿﺬ. اﻟﻜﻮﻓﺔ. Abstract This is a cross-sectional study was conducted in Al-Kufa city/ Al-najaf Al-Ashraff province to determine the prevalence of pityriasis alba in the children of primary school. Study aims to determine the prevalence of Pityriasis alba in the children of primary schools. The setting of study: The study was conducted in Al-Kufa city /Al-Najaf Al-Ashraff province. Data collection : During the period from 1/4/2011 to 31\4\2012. The study sample: The total number of primary school submit ةted was 38 and the number of total pupil were 18356, and founded the number of infected pupil with pityriasis alba was 1935 with percentage (10.54%), number of male was 1067 (55.14%) and number of female was 868(44.86%). Data analysis: The data was analyzed through the application of descriptive statistical analysis that include(Chi-square) , and application of inferential statistical analysis that include (chi-square , P value). Results: The results of this study showed that the prevalence of pityriasis alba in the male is more than in the female, the more exposed infected age group was between (6-8 year). The white patches were more clear in dark color, appearance of patches in the face was more clear than other parts of the body. The number of pupil who suffered from anemia was 232 (12%), and 242 (12.5%) suffered from infected with Oxyuris vermicularis, Giardia lamblia, Entamoeba histolytic and other parasites. Conclusion: We conclude in this study that the prevalence of pityriasis alba was acceptable in comparison with other similar studies in many countries, this may reflect some negligence, poor personal hygiene and nutrition in primary schoolchildren, care health provided was inadequate. Recommendation: Based on the above results, this study recommended that the primary health care sector must examine the children in beginning of study. Periodic skin examination is of a high value. Health education for teachers and parents on sound personal hygiene and clean environment are recommended.
... Vitiligo presents with completely depigmented macules and patches with perifollicular retention of pigment, which is distinct from TV, which shows hypopigmentation and folliculocentric loss of pigment. Pityriasis alba can present with superficial scale similar to tinea versicolor but primarily affects children, favors the cheeks, and lacks the evoked scale sign [23]. ...
Tinea versicolor (TV) is typically an asymptomatic fungal infection of the stratum corneum owing to Malassezia overgrowth. It presents as hypoor hyperpigmented macules with fine scale that coalesce into patches on the trunk, neck, and/or arms. Presented in this report is a 34-year-old man with an interesting case of folliculocentric tinea versicolor manifesting as perifollicular hypopigmented macules on the lower back.
... Numerous skin diseases could be considered in differential diagnosis, including idiopathic guttate hypomelanosis, punctate vitiligo, hypomelanotic macules associated with genodermatosi such as Darier disease (4), and disseminate macular leucodermia as sequellae of previous inflammatory disease (5). To date, no effective standard treatment is available for WL. ...
The term “white lentiginosis” (WL) was first reported in 1994 by Grosshans E et al (1), identifying a hypopigmented disorder of healthy individuals, clinically characterized by lenticular white macules and occurring most frequently in dark-colored individuals of phototype IV-V with a typical distribution on the trunk, décolleté, neck, hands and on the extensor surface of the upper arms. It is an acquired disorder with a chronic course and characterized by peculiar histhopathological features of lentiginosis hyperplasia with hypopigmentation. This article is protected by copyright. All rights reserved.
Vitiligo is a common depigmentation skin disease that affects the quality of life in many patients. This study aims to investigate the effect of Medicago sativa methanol extract on the treatment of skin hypopigmentation disorders. Antioxidant activity and phytochemical constituents of the extract were determined using DDPH assay, Folin-Ciocalteu, AlCl 3 and HPLC-MS/MS analysis. Oil in water (o/w) creams were prepared to contain the methanolic extract, and applied to hydroquinone-induced depigmentation in vivo model and further challenged in combination with UVA light exposure. Skin and hair colors were visually scored and evaluated at different time intervals, and histopathological examinations of skin layers and hair follicles were performed. Results showed total phenolic content of 187.70 mg/g, equivalent to gallic acid, and total flavonoid content of 21.97 mg/g, equivalent to quercetin. Most interestingly, the extract showed an antioxidant percent inhibition activity of 71%. Moreover, the HPLC-MS/MS detection revealed the presence of 18 compounds including P-coumaric acid and antioxidants flavonoids, of those are 7 compounds not previously detected in this species. The in vivo study showed a remarkable skin and hair pigmentation effect on plant extract treated groups, compared to the reference, placebo and control groups. Histopathological examinations showed the growth of coloured hair follicles in the dermis and epidermis layers of the extract treated mice. In conclusion, the study suggests the use of M. sativa extract in enhancing the pigmentation process in hypopigmented skin and hair if combined with UVA light. Therefore, M. sativa extract can be considered a potential treatment for vitiligo.
Objectives: This study was conducted to assess the prevalence of Pityriasis Alba (PA) and its determinant among the elementary school students.
Methods: A school-based cross sectional study was conducted during the scholastic year 2017-2018 on primary school students in one of the Egyptian villages. A self-reported questionnaire, history with clinical examination sheet and laboratory investigation sheet were used to collect data.
Results: The overall prevalence of PA accounted for 19.8%. Age of 10-11 years, sun exposure, personal history of atopy, past history and siblings history of PA and parasitic infestation were significant determinants of current lesions in children (P =0.04, 0.03, 0.046, 0.001, 0.01 and 0.011 respectively). Having past history of PA was the only single significant risk factor for the current lesions (P< 0.001, AOR= 6.99 and CI= 2.5-19.7)
Conclusions: PA affected nearly one fifth of elementary school students. Although, the 5th graders, sun exposure, personal history of atopy, past history of PA, siblings history of PA and parasitic infestation were significant determinants among school children, the past history of affection with PA was the only single significant risk factor for the current lesions. Health education on sound personal hygiene, balanced diet, clean environment, healthy living status is recommended.
Keywords: Pityriasis Alba; prevalence; determinants; elementary school; Egyptian village.
Acquired hypopigmented skin changes are commonly encountered by dermatologists. Although hypopigmentation is often asymptomatic and benign, occasional serious and disabling conditions present with cutaneous hypopigmentation. A thorough history and physical examination, centered on disease distribution and morphological findings, can aid in delineating the causes of acquired hypopigmented disorders. Part II of this two-part series focuses on conditions with a hypopigmented phenotype. Early diagnosis and appropriate management of these disorders can improve a patient's quality of life, halt disease progression, and prevent irreversible disability.
Loss of pigment, whether hypopigmentation, depigmentation, or dyspigmentation, is a common complaint in pediatric patients of color. Childhood loss of pigment can be divided into localized or generalized variants, congenital (under the age of 2 years at onset) or acquired, and by etiology. The following chapter identifies strategies to identify causes of pigment loss in children and reviews specific diagnoses commonly noted and pertinent to or with nuances in children of color worldwide.
Dermatology is a visual specialty, and an accurate description of a “rash” makes it more likely that the practitioner will be able to classify a particular eruption and rapidly arrive at the right diagnosis. This chapter begins with definitions of dermatologic terms, which when used in conjunction with Table 5-1 can serve as a guide to the most common diagnoses. Definition of terms Primary lesions Macule A flat, non-palpable, superficial skin color change that is <1 cm in diameter. A macule can be red, brown, yellow, or white. Patch A macule that is >1 cm in diameter. Papule A firm, palpable, elevated lesion that is <1 cm in diameter. A papule may be flat-topped, dome-shaped, or pointed. Plaque A papule that is >1 cm in lateral diameter. It is a broad, elevated, flat-topped solid lesion often formed by a confluence of several papules. In contrast to a nodule, it does not possess increased depth, and is a “plateau,” rather than a “glacier.” Nodule A papule that is enlarged in all three dimensions: length, width, and depth. It may be dome-shaped or slope-shouldered, but the discriminating characteristic is increased depth compared to a papule or plaque. Tumor A large nodule. Wheal An evanescent, edematous, smooth, raised, pink to red lesion. The classic description is “hive-like.” Vesicle A sharply circumscribed, elevated, clear fluid-filled lesion that is <1 cm in diameter. A vesicle is often thin-walled and fragile, so it ruptures easily. Therefore, patients may present instead with small erosions (de-roofed vesicles).
Résumé
Introduction
Les lésions leucodermiques sont un motif fréquent de consultation chez l’enfant. Leur signification n’est pas toujours évidente lors de la première consultation. L’objectif de l’étude était d’analyser les diagnostics associés aux leucodermies chez les enfants et les examens complémentaires proposés afin d’essayer de proposer une prise en charge diagnostique à partir des données de la littérature.
Matériel et méthodes
Une recherche d’articles scientifiques a été réalisée en interrogeant la base de données informatique MEDLINE avec les mots clés « leucoderma children review », « leucoderma Ito » et « nevus depigmentosus ». Tous ceux qui abordaient les causes des leucodermies, l’intérêt des examens complémentaires ou la démarche diagnostique ont été inclus.
Résultats
Quatre cent trente-cinq articles étaient référencés, 179 ont été retenus. Six proposaient une démarche diagnostique et 15 des examens complémentaires à réaliser en fonction du phénotype.
Discussion
La plupart des lésions leucodermiques peuvent être classées nosologiquement dès la première consultation en fonction de leur caractère congénital ou acquis et de leur localisation diffuse ou circonscrite. Cependant, certaines situations imposent un bilan complémentaire et/ou doivent faire chercher une entité associée. La démarche diagnostique et surtout les examens à réaliser sont très peu décrits dans la littérature. Nous proposons une conduite à tenir pratique devant une leucodermie, afin d’aider le clinicien à affiner son bilan complémentaire.
Pityriasis alba is a common cutaneous disorder characterized by asymptomatic hypopigmented patches on the face, neck, trunk and proximal extremities of children and young adults. Its pathogenesis has not been definitely clarified. Pityriasis alba is considered to be a low-grade eczematous dermatitis and is regarded as a minor feature of atopic dermatitis. Possible comorbid disorders described in association with pityriasis alba are nutritional deficiency, anemia and parasitic infestations; however, these are exclusively observed in children of poor socioeconomic conditions. In the past, a pathogenic implication of several microorganisms, in particular Gram-positive bacteria, has repeatedly been proposed but never confirmed. Pityriasis alba has no reliable treatment, but it usually resolves with time. Emollients, mild topical steroids and pimecrolimus may aid to accelerate the repigmentation.
Dermatophile has a new format. From now on, it will take the form of a short quiz to test and inform your knowledge of dermatology relevant to paediatrics. Any suggestions for improvement or topics you would like to be covered are welcome. Please email comments and feedback to p-lio@northwestern.edu. Theme: Scaly rashesSelect the one best answer from the following: Tinea corporis (ringworm)Acanthosis nigricansConfluent and reticulated papillomatosis (CARP)Pityriasis (tinea) versicolorDrug hypersensitivity eruptionScabies infestationTerra firma-forme dermatosisAnswers to the following quiz questions can be found on page 39.
Pityriasis (tinea) versicolor is a superficial fungal infection of the stratum corneum by the lipophilic yeast Malassezia spp. It is very common and can often be diagnosed clinically. We illustrate a simple but very useful clinical manoeuvre to help secure the diagnosis when mycologic examination is unavailable and the clinical diagnosis is uncertain: the evoked scale sign.
A 12-year-old African-American male presented with a 4-week history of multiple non-pruritic hyperpigmented lesions on his …
To assess the safety and efficacy of topical 0.1% tacrolimus vs 0.05% clobetasol propionate.
Randomized double-blind trial.
Department of Dermatology, Hospital Central Dr Ignacio Morones Prieto, San Luis Potosí, México.
From 20 children with vitiligo, 2 symmetrical lesions of about the same size and evolution time were selected. They were devoid of any topical or systemic therapy for 2 months prior to inclusion. Interventions Treatment with topical tacrolimus and clobetasol for a 2-month period.
The grade of repigmentation was evaluated by color slides at baseline and again at every 2-week visit. The slides were analyzed by 2 clinicians unrelated to the study and by a morphometric digitalized computer program. Characteristics of pigment, time of response, symptoms, telangiectasias, and atrophy were evaluated every 2 weeks.
Eighteen (90%) of the 20 patients experienced some repigmentation. The mean percentage of repigmentation was 49.3% for clobetasol and 41.3% for tacrolimus. Lesions in 3 patients using clobetasol presented atrophy, and 2 lesions incurred telangiectasias; tacrolimus caused a burning sensation in 2 lesions.
Tacrolimus proved almost as effective as clobetasol propionate to restore skin color in lesions of vitiligo in children. Because it does not produce atrophy or other adverse effects, tacrolimus may be very useful for younger patients and for sensitive areas of the skin such as eyelids, and it should be considered in other skin disorders currently treated with topical steroids for prolonged periods.
Vitiligo is a skin disease with a worldwide prevalence ranging from 0.5% to 4%. Conservative therapies include photochemotherapy, phototherapy with UVB radiation (broadband UVB 290–320 nm, narrow band UVB 311 nm), systemic steroids and pseudocatalase. Modern therapeutic options include treatment with topical immunomodulators (tacrolimus, pimecrolimus), analogues of vitamin D3, excimer laser and surgery/transplantation. Our analysis compares these therapies for vitiligo and the evidence levels supporting their effectiveness.
Conclusions: The face and neck respond best to all therapeutic approaches, while the acral areas are least responsive. For generalized vitiligo, phototherapy with UVB radiation is most effective with the fewest side effects; PUVA is the second best choice.Topical corticosteroids are the preferred drugs for localized vitiligo. They may be replaced by topical immunomodulators which display comparable effectiveness and fewer side effects.The effectiveness of vitamin D analogues is controversial with limited data. Surgical therapy can be very successful, but requires an experienced surgeon and is very demanding of time and facilities, thus limiting its widespread use. L-phenylalanine therapy appears effective on the face but enjoys neither widespread use nor extensive data support. No single therapy for vitiligo can be regarded as the most effective as the success of each treatment modality depends on the type and location of vitiligo.
Vitiligo, an autoimmune disorder characterized by localized and/or generalized depigmentation of the skin and/or mucous membranes, is a well-recognized entity. The imperatives of its epidemiology both in rural India and in global reckoning have been highlighted frequently. Its morphology is striking and is characterized by asymptomatic ivory/chalky white macule(s) that may be frequently surrounded by a prominent pigmented border, the 'trichrome vitiligo'. However vitiligo may have morphological variations in the form of: trichrome, quadri-chrome, penta-chrome, blue and inflammatory vitiligo. Its current topographical classification into segmental, zosteriform and nonsegmental, areata, vulgaris, acrofacialis and mucosal represent its well acclaimed presentations. Its adult and childhood onset is well appreciated as also its presentation in males and females. Occasionally, it may be possible to identify triggering factors. Vitiligo may be associated with cutaneous, ocular and systemic disorders, the details of which are discussed in this article.
Even though pityriasis alba is commonly encountered in dermatological practice, there is paucity of Indian studies on the subject. A clinico epidermiological study was carried out in 200 patients attending the skin department of Command Hospital, Air Force, Bangalore. Atopic background was detected in 85.5% of cases. Bacterial and fungal culture studies failed to reveal any infective aetiology. Helmenthiasis and iron deficiency anaemia were detected in 15.5% and 16.5% of patients respectively. However no other nutritional deficiency was observed in the present study. Majority (84.5%) of patients had lesions of less than 6 months duration at the time of presentation. Face was involved in 91% of patients and generalized pityriasis alba was observed in 3 patients, all of them being infants. Pigmenting pityriasis alba was observed in 7 patients. Hyperkeratosis, parokeratosis, acanthosis, spongiosis and perivascular infiltration were the consistent histological features of pityriasis alba.
Vitiligo is an acquired skin disorder caused by the disappearance of pigment cells from the epidermis that gives rise to well defined white patches which are often symmetrically distributed. The lack of melanin pigment makes the lesional skin more sensitive to sunburn.
Vitiligo can be cosmetically disfiguring and it is a stigmatizing condition, leading to serious psychologic problems in daily life. It occurs worldwide in about 0.5% of the population and it occurs as frequently in males as it does in females. The cause is unknown, but might involve genetic factors, autoimmunity, neurologic factors, toxic metabolites, and lack of melanocyte growth factors. Since a causative (gene) treatment is not (yet) available, current modalities are directed towards stopping progression and to achieving repigmentation in order to repair the morphology and functional deficiencies of the depigmented skin areas.
Many treatments have been used for some time; however; there are some new developments: narrowband ultraviolet (UV) B (311nm) therapy, the combination of corticosteroid cream + UVA therapy, and the transplantation of autologous pigment cells in various modalities. In widespread vitiligo, residual pigment can be removed by depigmentation agents. Sunscreens, camouflage products, and good guidance may help the patient cope better with the disease.
A case of congenital vitiligo with its distribution over both lower extremities and trunk is reported.
The most common disorders of hypopigmentation in children are pityriasis alba, vitiligo, nevus depigmentosus, and tinea versicolor. Pityriasis alba usually presents as ill defined, scaly patches of hypomelanosis on the cheeks of children with an atopic diathesis. The face is also a favored site for vitiligo, but the distribution is periorificial, and the pigment loss is complete because of a destruction of melanocytes. Vitiligo is an acquired, progressive disorder in contrast to nevus depigmentosus, which is a stable, congenital leukoderma. The localized form of nevus depigmentosus must be distinguished from an ash leaf spot, the earliest cutaneous manifestation of tuberous sclerosis, whereas the systematized form may be confused with hypomelanosis of Ito, another neurocutaneous disorder. The lesions of tinea versicolor favor the upper trunk of adolescents, and potassium hydroxide examination of the associated scale reveals hyphal and yeast forms of P. orbiculare. Any inflammatory process in the skin such as dermatitis or psoriasis can resolve with areas of hypopigmentation.
Vitiligo is an acquired skin disorder caused by the disappearance of pigment cells from the epidermis that gives rise to well defined white patches which are often symmetrically distributed. The lack of melanin pigment makes the lesional skin more sensitive to sunburn. Vitiligo can be cosmetically disfiguring and it is a stigmatizing condition, leading to serious psychologic problems in daily life. It occurs worldwide in about 0.5% of the population and it occurs as frequently in males as it does in females. The cause is unknown, but might involve genetic factors, autoimmunity, neurologic factors, toxic metabolites, and lack of melanocyte growth factors. Since a causative (gene) treatment is not (yet) available, current modalities are directed towards stopping progression and to achieving repigmentation in order to repair the morphology and functional deficiencies of the depigmented skin areas. Many treatments have been used for some time; however; there are some new developments: narrowband ultraviolet (UV) B (311 nm) therapy, the combination of corticosteroid cream + UVA therapy, and the transplantation of autologous pigment cells in various modalities. In widespread vitiligo, residual pigment can be removed by depigmentation agents. Sunscreens, camouflage products, and good guidance may help the patient cope better with the disease.
Pityriasis versicolor is a common superficial fungal infection of the skin. It is caused by Malassezia spp., which are normal human saprophytes. Under certain conditions, both exogenous and endogenous, the fungus can convert from a yeast to a pathogenic mycelial form. This alteration results in mild inflammation of the skin, and in characteristic clinical and histological changes. The taxonomy of Malassezia spp. has recently been modified to include six obligatorily lipophilic species, all of which can be found on human skin, plus one non-obligatorily lipophilic species, which only rarely colonizes human hosts.
Learning objectives At the conclusion of this learning activity, participants should be aware of the role of Malassezia in the development of pityriasis versicolor, the clinical and histological changes arising from this dermatosis, and the diagnosis and treatment of this disorder.
The aetiology of pityriasis alba (PA), a common dermatosis in childhood, is still controversial. The objective of this study was to assess the possible aetiopathogenic factors of this disease in infants.
Forty-four patients with PA and 31 healthy children were examined and compared. Personal hygiene habits, sun exposure, presence of Staphylococcus aureus in nasal fossae and presence of major or minor signs of atopy were assessed during anamnesis and physical examination. Susceptibility to ultraviolet (UV) B radiation was measured by the onset of a contact hypersensitivity reaction to diphenylcyclopropenone in individuals sensitized in previously irradiated areas.
The prevalence of PA was higher in individuals with darker skin, in high phototype categories, as well as in males. The number of daily baths and sun exposure between 10.00 h and 15.00 h were significantly higher in the PA group when compared with controls (P = 0.03 and P = 0.0015, respectively). The presence of atopy signs was more common in pityriasis patients (P = 0.002). Susceptibility to UVB radiation was 29.6% in the PA group vs. 29.0% in the control group; nevertheless, important differences were found after stratification in order to control possible confounding factors. The presence of S. aureus in the nostrils was equal in both groups.
Our results confirm that PA, in our population, is more prevalent in males and in individuals in higher phototype categories. In those with inadequate personal hygiene and sun exposure habits the disease is more accentuated, demonstrating that the xerosis presenting in individuals with atopic diathesis is an important element in the development of the disease. S. aureus is not an important aetiopathogenic factor in PA. Susceptibility to UVB becomes important when related to the patient's phototype.
The new antifungal triazoles itraconazole and fluconazole have revolutionized the treatment of pityriasis versicolor. Both drugs have shown promising results in different dose schedules.
To compare the efficacy and safety of single oral dose treatment with fluconazole versus itraconazole in patients with pityriasis versicolor.
A total of 40 patients with pityriasis versicolor were allocated randomly to group A and group B. A single dose of fluconazole (400 mg) or itraconazole (400 mg) was given orally to group A or group B patients, respectively. Patients were assessed mycologically by KOH and culture. Culture was done from lesional and perilesional skin to quantify growth and to observe the effect of these drugs and the persistence/reappearance of the fungus in relation to relapse at 2 and 8 weeks. Relapse was defined as reappearance or worsening of clinical signs and symptoms or positive KOH/culture after initial improvement.
Thirteen (65%) patients in the fluconazole group and 4 (20%) patients in the itraconazole group became culture negative at the end of 8 weeks. Relapse was found to be higher in the itraconazole group compared to the fluconazole group (60 vs. 35%). A direct correlation was found between the relapse rate and positivity of perilesional skin for Malassezia furfur.
In the same dosing, fluconazole was found to be more effective than itraconazole; however, both drugs were found to be safe.
Superficial fungal infections arise from a pathogen that is restricted to the stratum corneum, with little or no tissue reaction. In this Seminar, three types of infection will be covered: tinea versicolor, piedra, and tinea nigra. Tinea versicolor is common worldwide and is caused by Malassezia spp, which are human saprophytes that sometimes switch from yeast to pathogenic mycelial form. Malassezia furfur, Malassezia globosa, and Malassezia sympodialis are most closely linked to tinea versicolor. White and black piedra are both common in tropical regions of the world; white piedra is also endemic in temperate climates. Black piedra is caused by Piedraia hortae; white piedra is due to pathogenic species of the Trichosporon genus. Tinea nigra is also common in tropical areas and has been confused with melanoma.
The yeasts of the genus Malassezia have been associated with a number of diseases affecting the human skin, such as pityriasis versicolor, Malassezia (Pityrosporum) folliculitis, seborrheic dermatitis and dandruff, atopic dermatitis, psoriasis, and--less commonly--with other dermatologic disorders such as confluent and reticulated papillomatosis, onychomycosis, and transient acantholytic dermatosis. Although Malassezia yeasts are a part of the normal microflora, under certain conditions they can cause superficial skin infection. The study of the clinical role of Malassezia species has been surrounded by controversy because of their fastidious nature in vitro, and relative difficulty in isolation, cultivation, and identification. Many studies have been published in the past few years after the taxonomic revision carried out in 1996 in which 7 species were recognized. Two new species have been recently described, one of which has been isolated from patients with atopic dermatitis. This review focuses on the clinical, mycologic, and immunologic aspects of the various skin diseases associated with Malassezia. It also highlights the importance of individual Malassezia species in the different dermatologic disorders related to these yeasts.
Eighteen patients with a clinical diagnosis of vitiligo, aged between three and 12 years (mean 8.9 years), were enrolled in this study in order to evaluate the efficacy and tolerability of topical calcipotriol in the treatment of childhood vitiligo. Six patients (33.3%) were males and 12 were females (66.7%). Fourteen patients (77.8%) had focal vitiligo, two (11.1%) had mucosal vitiligo and two (11.1%) had segmental vitiligo. The face was involved in 11 patients (61.1%). The treatment was applied twice daily as 50 microg/gm cream in nine patients and as ointment in the remaining patients. Treatment assessment was carried out clinically at 2 weeks, and then monthly for 4-6 months. Four patients (28.6%) were excluded from the study (one due to irritation and three due to lost contact in follow-up). Fourteen patients (71.4%) completed the treatment course (> 3 months). Of the treated patients, ten (77.8%) showed improvement and four patients (22.2%) had no response. Among responders, three patients (21.4%) showed complete resolution, four (28.6%) showed 50%-80% improvement and three patients (21.4%) showed 30% to < 50% improvement. Only one patient (5.5%) developed irritation. In conclusion, calcipotriol is an effective treatment in vitiligo. Better results are obtained with ointment than with cream. Calcipotriol can be helpful in children in whom potent steroids and PUVA are not advisable.
Sunlight and psoralen and ultraviolet A (PUVA) are risk factors for the development of squamous cell carcinoma (SCC) and, to a lesser extent, basal cell carcinoma (BCC). Ultraviolet B (UVB) therapy, used for the treatment of psoriasis, might also increase the risk of these tumors. We studied the relation of skin cancer incidence to UVB use among 1380 adult subjects enrolled in a long-term safety trial of PUVA therapy. We used negative binomial regression models to quantify the association between UVB and the development of non-melanoma skin cancer (NMSC), controlling for known confounders. High UVB exposure (> or =300 treatments vs <300 treatments) was associated with a modest but significant increase in SCC (adjusted incidence rate ratio (IRR)=1.37, 95% confidence interval (CI)=1.03-1.83) and BCC (adjusted IRR=1.45, 95% CI=1.07-1.96) risk. Among patients with <100 PUVA treatments, high UVB exposure was significantly associated with the development of SCC (adjusted IRR=2.75, 95% CI=1.11-6.84) and BCC (adjusted IRR=3.00, 95% CI=1.30-6.91) on body sites typically exposed to UVB therapy but not on chronically sun-exposed sites typically covered during therapy. For adults with high UVB exposure levels, UVB confers a modest increase in NMSC risk, much less than that observed with PUVA. Therefore, UVB remains a relatively low-risk treatment for psoriasis.
We demonstrate the utility of the Wood's light in a practice that specializes in the evaluation of pigmented lesions. The Wood's light assisted the physician in locating the site of a completely regressed primary cutaneous melanoma, determining the clinical borders of a lentigo maligna melanoma, differentiating between agminated naevi and a naevus spilus and detecting the recurrence of pigmentation after the excision of a dysplastic naevus, and also proved useful in monitoring a large segmental speckled atypical lentiginous naevus for change. Despite the availability of many 'high-tech' imaging and diagnostic devices designed to evaluate skin lesions, the relatively simple Wood's lamp continues to be of great value. We encourage physicians not to abandon the use of the Wood's light in their clinical practice.
Eighty-eight consecutive children presenting with vitiligo to a hospital dermatology clinic in a 1-year period were assessed clinically, and for autoimmune and endocrine disorders. Vitiligo started between 8 and 12 years of age in 51% of our patients. A positive family history was obtained in 27.3% of the patients. Vitiligo vulgaris was the most common clinical type seen. Three patients, though clinically asymptomatic, showed antithyroid antibodies. Our results are compared with those published previously on the subject.
Pityriasis alba (PA) is a common benign condition in children that has no definitive treatment. Its etiology and pathogenesis are still poorly understood. Recent studies have found direct correlations between the incidence of PA and atopy, amount of sun exposure, lack of sunscreen use, and frequency of bathing. It is often an incidental finding on physical examination because it is usually asymptomatic. Although treatment with emollients and mild topical corticosteroids may accelerate the repigmentation, they have limited efficacy. Without intervention, the lesions normally resolve within months to years. Extensive PA and pigmenting PA are rarer variants.
To analyze the relationships among different Malassezia species and pityriasis versicolor, the only human disease in which the etiologic role of these fungi is fully accepted (although the species implicated remains a matter of discussion).
Since 1996, after the taxonomic revision of the genus, a limited number of papers analyzing the role of the different Malassezia species in pityriasis versicolor have been published or were the subject of presentations in congresses; there were only four in the past year. This paper discusses the results of these works, comparing them with results of the authors' most recent study in this field, conducted over the past 16 months.
Most of the studies published thus far now show that Malassezia globosa is the predominant species found in the lesions of pityriasis versicolor, at least in temperate climates. The authors' recent findings confirm these results. The etiologic role of M. globosa in pityriasis versicolor is based, even more than on its isolation in a high percentage of cultures, on its identification by direct microscopy as typical globose yeast cells producing pseudohyphae in almost 100% of cases. The confirmation of the pathogenic role of this species in pityriasis versicolor could help in understanding these conditions, which are still unclear, which promote its transformation from the saprophytic stage present in healthy skin to the parasitic one, and could also help in selecting the best therapeutic measures.
Pityriasis alba (PA) is a frequent reason for dermatological consultation because of its chronic course, tendency to relapse and aesthetic impact.
In view of its strong association with atopic dermatitis, the objective of this open-label study was to assess the efficacy and safety of tacrolimus ointment in the treatment of PA compared with the efficacy of moisturizers.
The study population consisted of 60 individuals of phototype III or IV according to Fitzpatrick's classification, aged 6-21 years. Patients were randomly assigned to one of two groups. Subjects in group A were instructed to apply tacrolimus ointment 0.1% twice daily, 12 h apart, on all hypopigmented macules. Standard moisturizers with SPF 20 sunscreen were used on all lesions applied at least 30 min apart from the tacrolimus ointment. Subjects in group B used solely the same moisturizers with sunscreen. Hypopigmented areas were evaluated at baseline and weeks 0, 3, 6 and 9 by investigators for scaling, hypopigmentation and pruritus on a scale of 0-3. Patient satisfaction was also recorded on a scale of 0-3. All adverse effects were recorded.
A statistically significant improvement through time, in hypopigmentation, pruritus and scaling was observed in both groups during the course of 9 weeks. Hypopigmentation resolved from a baseline score of 2.38+/-0.64 to 1.15+/-0.54 at week 3, 0.46+/-0.51 at week 6 and 0.00+/-0.00 at week 9 for the group applying tacrolimus ointment 0.1%. The difference in improvement between the two groups was statistically significant on all three assessments for hypopigmentation (P<0.001), and for pruritus on week 6 and 9 assessments (P<0.05). Three patients (11.5%) in the tacrolimus group reported a mild transient sensation of burning. All patients in the tacrolimus group reported they were completely satisfied or just satisfied with the treatment compared with only 50% of patients using the placebo.
Tacrolimus ointment 0.1% appears to be an effective and safe treatment for PA.
This study examines the extent of stigmatization experienced by vitiligo patients considering the visibility of the lesions.
363 vitiligo patients were assessed using the Experience with Skin Complaints (QES), Adjustment to Chronic Skin Disorders (ASC), and Sense of Coherence (SOC) questionnaires. Out of the total patients group two representative samples with 52 patients each were identified comparable for age, gender, and the duration of the skin disease, the first with visible and the second with invisible lesions.
Data indicate a significant negative correlation between the QES dimensions, except for 'Composure', and between coping scales with sense of coherence withstanding. The 'visible lesions' group scored higher compared to the 'invisible lesions' group on the two QES scales 'Self-Esteem' and 'Refusal', i.e., patients with visible lesions experienced a higher level of stigmatization.
This study provides new information which supports the notion that the stigmatization experience of vitiligo patients is psychologically relevant.
Vitiligo is a depigmentation disorder resulting from autoimmune destruction of cutaneous melanocytes. The psychosocial ramifications of this often disfiguring disease can be substantial. Half of the patients with vitiligo experience disease onset in childhood. Although largely similar to the disease in adults, pediatric vitiligo does have differences in epidemiology, associations, and treatment. We review vitiligo as it relates to the pediatric population, emphasizing key differences with adults and the latest treatment advances.
Use of topical corticosteroids for the treatment of pityriasis alba is limited by their potential side-effects, such as skin atrophy especially with long-term use on the face. Pimecrolimus cream 1% is a topical calcineurin inhibitor that has anti-inflammatory properties, lacks the cutaneous side-effects associated with steroids, and provide a potential benefit for the treatment of pityriasis alba.
This 10-patient, prospective, single-arm, open-label, single-center, 12-week, investigator-initiated proof of concept study assessed the efficacy, safety, and patient acceptance of pimecrolimus cream 1% twice daily. In addition to pimecrolimus cream, patients used facial emollient containing SPF 15 sunscreen and mild soap-free cleanser. Efficacy assessments were Investigator Global Assessment (IGA) of disease severity and evaluation of uneven skin color, scaling, eczema, follicular keratosis, and pruritus. All efficacy assessments were reported on a 4-point scale (0 = none to 3 = severe).
Of the 10 patients enrolled (aged: 12-35 years), all had intensive sun-exposure, 90% had skin type IV-V, and 80% completed the 12-week treatment. At baseline, mean IGA was 1.20 (mild-moderate), uneven skin color was 2.3 (moderate-severe) and scaling was 1.2 (mild). IGA decreased to 0.25 by week 12, uneven skin color improved by week 3 with near complete resolution by week 12 (mean = 0.38) and scaling resolved at week 3. Pruritus, eczema, and follicular keratosis remained at low levels from baseline throughout the course of the study. Patients consistently reported satisfaction with the treatment ("satisfied" or "very satisfied"). No adverse events were reported.
Pimecrolimus cream 1% may represent an alternative for the treatment of pityriasis alba.
One hundred and twenty patients with tinea versicolor who attended the outpatient department of Dermatology, K.M.C Hospital, Mangalore were studied with reference to their clinical features, age and sex distribution, relation to climate and personal habits. The disease was commonest among the age group of 21-30 years (30%). It was found to be distributed predominantly over the neck (71.6%), chest (58.3%) and back (70%). Inmost of the patients, lesions were observed first and also aggravated during summer months. One fourth of the patients either had systemic diseases or were on immuno-suppressant drugs. The disease was continuous in spite of taking treatment in 21.6% of patients. 38.3% of patients gave a positive family history. Even though the disease is resistant to treatment, avoiding the predisposing factors like increased sweating, sharing the towels and clothes, malnutrition, synthetic clothings will help to control the disease.
Vitiligo has been mentioned in the tomes of every major religion, with its first description dating back more than 3000 years, to the earliest Vedic and Egyptian texts. Despite this ancient recognition, confusion with disorders such as leprosy has been a problem throughout the ages. This has lead to the stigmatization of vitiligo sufferers. This is a social problem that is still widespread in some, but not all, parts of the world. The ancients also practiced phototherapy for vitiligo. This practice only became common in the Western world with development of psoralen plus ultraviolet A and later ultraviolet B phototherapy in the latter half of the 20th century. In this article, the history of vitiligo up until the end of the 20th century is outlined, covering medical, scientific, and social aspects.
Letters to the Editor are welcomed for publication (subject to editing). Letters must be signed by all authors, and must not exceed two pages of text including references. Letters should not duplicate material submitted or published in other journals. Prepublication proofs will not be provided.
Interventions for vitiligo
- Whitton Me
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Whitton ME, Ashcroft DM, Barrett CW, et al. Interventions for vitiligo. Cochrane Database Syst Rev 2006;1:CD003263.
A dictionary of dermatologic terms
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Carter RL, Leider M. A dictionary of dermatologic terms. 4th edn. Baltimore: Williams & Wilkins, 1992.