1. health and fitness
2. disease

How to diagnose and treat
Tinea versicolor
Pityriasi rosea
JEANNE STEMAN FINDLAY, NP, MN. CRNP. CCRP
P
ityriasis alba (p alba) is a common clinical finding
where distinctive posi-inflammatory hypopigmentation develops in association with
several common inflammatory dermatoses, such as
atopic and seborrheic dermatitis. The eruption is
characterized by symmetric hypopigmented, minimally
scaly, non-tender patches with fuzzy borders typically
found on sun-exposed areas of the face, trunk, and
extremities of children with dark pigmentation. It is
non-scarring, and primarily of cosmetic concern to
patients and parents, especially those with Fitzpatrick
skin type II to VI, as the blotchy appearance and
uneven skin tone associated with p alba may lake
longer to resolve.^ Fitzpatrick skin types refer to skin
pigment and an individual's tendency to burn or tan.
with I equal to very fair skin (always burns) and VI
equal to highly pigmented skin (always tans). They
are influenced by genetic factors and individual sun
exposure habits.
Pityriasi alba
pityriasis aiba
In 2006, Burrall reported on study results of the nine
most common dermatologie skin diagnoses reported
in a Washington, DC dermatology practice.' These
diagnoses were; acne, eczema, pigmentary changes,
seborrhea, alopecia, fungal infections, warts, tinea
versicolor, and keloids. Pigmentary changes ¡other than
vitiligo and primarily p alba and associated disorders]
ranked third among black patients at 9.0%, compared
to white patients where it ranked seventh at 1.7%. The
frequency of occurrence, distribution on the face and
sun-exposed areas, and the persistence oí pigment
changes presents a frequent challenge to physicians
wben it comes to diagnosing and managing these
patients and their families.
Environmental factors such as heat, humidity, and
amount of sun exposure can make pigment changes
worse in patients with p alba. Hygiene such as frequent,
lengthy, and hot showers can affect pigment changes
as well.' Irritation from harsh soaps and hot water
MS. FINDLAY is an instructor and research coordinator in the Department of Dermatology, Division of Pédiatrie Dermatology, Johns
Hopkins School cf Medicine, Baltimore, and a doctoral student at the JHU School of Nursing,
The author has nothing to disclose in regard to affiliations with, or financial interests in, any organization that may have an interest in
any part of this article,
4 www.contemporarypediatrlcs.com Vol. 25, No, 10 (suppi)
PITYRIASIS ALBA
PityriasI rosea
Segmental vitíligo
and not enough emollients can lead to drying, scaling,
and postinflammatory pigmentary changes. P alba
is also seen more frequently in individuals who have
atopic disease or a family history of eczema.^ Patches
of p alba tend to be exacerbated by non-uniform
tanning with intense sun exposure, particularly in the
summer. This may be partly attributed to the decreased
number of normally functioning melanocytes within
the affected areas.^ However, there are some structural
and functional differences among ethnic skin and white
skin. For example, Asians have the highest lipid content
in the stratum corneum; African Americans have the
lowest."^ Increased dermal reactivity and exaggerated
pigment changes are more common in patients with
Fitzpatrick skin types V+.^
Pathogenesis
Attempts to isolate a causative organism have been
unsuccessful.^ P alba probably results primarily from
inflammation involving the epidermis and superficial
dermis, which can interfere with normal pigmentation.
Specifically, it is thought that dry, itchy skin with
scratching is a key part of this inflammatory process,
which interferes with melanasome transfer.^ P alba
Tinea corporis
occurs worldwide in both genders and all races,
although it is more obvious in skin of color.^
Differential diagnoses include a number of disorders
that cause inflammation in the dermis, including
plaque psoriasis, discoid eczema, lupus erythematosus,
hypopigmented mycosis fungoides, hypopigmented
sarcoid, pityriasis versicolor, tinea corporis, contact
dermatitis, progressive macular hypomelanosis, leprosy,
and seborrheic dermatitis. Disorders that are not
associated with inflammation but rather dysfunction
of melanocytes or the absence of decreased number
of melanocytes include vitiligo, nevus depigmentosus,
and guttäte hypomelanosis.
In vitiligo, the edges of the lesions are sharply
demarcated, depigmented, and lack the subtle
inflammatory changes seen in p alba.
Progressive macular hypomelanosis (PMH) is
characterized by non-pruritic, non-tender, ill-defined
and often coalescing, non-scaly hypopigmented patches
on the trunk. These lesions rarely involve the head
or neck.^ Proprionabacteria acne is known to be a
causative agent in PMH.*^
Fungal and bacterial cultures may help in the
differential diagnosis if it includes pityriasis versicolor,
OCTOBER 2008 CONTEMPORARY PEDIATRICS 5
PITYRIASIS ALBA
tinea corporis, seborrhea, or progressive macular
bypomelanosis. Wood lamp examination will not
belp witb any of these disorders because they all bave
epidermal pigment reduction. Wood lamp examination
may be used to detect ash leaf macules in very fairskinned individuals, if there is suspicion of tuberous
sclerosis.
Skin biopsy is recommended for persistent or
recalcitrant cases, especially
in a patient with no pruritis
or history of atopy, to exclude
Taken
patient witb hypopigmented
mycosis fungoides in which
Patients should be
atypical lymphocytes infiltrate
the
epidermis.
Histologie
reassured that the
findings consistent with p alba
include epidermal spongiosis,
pigment changes
acanthosis, and parakeratosis.''
are not soarring.
permanent, or
Treatment
Before initiating any treatment,
it is important to target the
primary
disorder associated
underlying
with the pigment changes
systemic process.
associated with p alba. There
is little research to demonstrate
evidence-based effectiveness of
recommended treatments such as steroids, keratolytics
(lachydrin), 1% crude coal tar in a 1% base, '/2 strength
Pragmatar ointment (discontinued for distribution in
2006), 2% Zetar (coal tar shampoo) in Coraran cream,
pimecrolimus cream, tacrolimus ointment, and berbal
and homeopathic preparations. All of the above have
been recommended.
indicative of an
Tar-containing topicals are unfavorable both from an
efficacy standpoint and patient adherence. Low-dose
topical steroid preparations bave been prescribed for
short-term use to manage p alba, primarily for their
anti-inflammatory effects.
Pimecrolimus cream has sbown efficacy and
increased patient satisfaction in managing scalp
seborrhea and p alba in African American adult
patients, in small, open-label studies.'"^' In an openlabel, placebo-controlled study, Tacrolimus ointment
bas shown safety and efficacy in 60 pediatric-aged
patients with p
^^
6 www.contemporarypediatrics.com Voi. 25, No, 10 (suppl)
Two herbal and one homeopathic topical medicines—
Sitrotax, Albatab, and Albitin—all claim to be effective
in "curing" pityriasis alba. Tbe berbal preparation
Albatab purports to be clinically tested, but the results
of the clinical trial are "to be posted soon" on their Web
site, www.albatab.com.
Patient education
Patients should be reassured that the pigment changes
are not scarring, permanent, or indicative of an
underlying systemic process. Discussion witb the parent
and/or patient should mention that treatment of the
primary complaint will also resolve p alba. Emphasize
adherence to consistent, year-round applications of
bland emollients and sunscreen, or an emoUientbased sunscreen, as p alba appears more prominent
in sun-tanned skin. Several sunscreens have emollient
information (eg, water-based vs oil-based) listed on
the label; if not listed, it is best to cbeck with the
pharmacist.
Sunscreen use should be recommended to all patients
with all skin types. It sbould also be emphasized tbat
every child, including tbose with fair skin or more
pigmented skin, should use sunscreen in addition to
sun-protective clothing and bats." •
References
1. Kristal L, Klein PA: Atopic dermatitis in infants and children: An
update. Pediatr Clin N Am 2000:47:877
2. Burrall B: Skin of Color. American Academy of Dermatology 64th
Annual Meeting, March 3, 2006, San Francisco, Calif. Accessed September 12, 2008
3. Weber MB, de Avila LGS, Cestari TF: Pityriasis alba: epidemiological, clinicai. and therapeutic aspects. Sociedade Brasileira de Dermatología 2000:75(3)
4. Richards GM, Oresajo CO, Haider RM: Structure and function of
ethnic skin and hair, Dermatol Clin 2003;21:595
5. Nordlund JJ, Sober AJ, Hansen TW: Periodic synopsis on pigmentation. JA>ÍO 1985:12;361
6. Ali M, Zeina B, Mansoor S, et al: Pityriasis Alba. eMedicine. last
updated April 3, 2006
7. Relyveid GN, Menke HE, Westerhof W: Progressive macular
hypomeianosis: an overview. Am J Clin Dermatol 2007:8:13
8. Westerhof W, Reiyveid GN, Kingswijk M, et ai: Propionobacterium
acnes and the pathogenBsis of progressive macular hypomeianosis.
Arch Dermatol 2004;140;210
9. Martin RF, Lugo-Somoiinos A, Sánchez JL: Ciinicopathologic study
on pityriasis alba. Bol Asoc Med PR 1990;82:463
10. High WA, Pandya AG: Pilot trial of 1% pimecrolimus cream in the
treatment of seborrheic dermatitis in African American adults with
associated hypopigmentation, J AAD 2006:54:1083
11. Fujita WiH, McCormick CL, Parneix-Spake A: An expioratory study
to evaluate the efficacy of pimecrolimus cream 1% for the treatment of
pityriasis aiba. Int J Dermatol 2007;46:700
12. Rigopouios D, Gregoriou S, Charissi C, at al: Tacrolimus ointment
0.1% in pityriasis aiba: an open-labei, randomized, placebo-controlled
study. BrJ Dermatol 2006:155:152
13. Robinson JK, Rigel DS, Amonette RA: Summertime sun protection
used by adults for their chiidren. Am Acad Dermatol 2000:42:74