Pityriasis Alba with Poliosis Tayyaba Gul Malik1, Muhammad Khalil1 and Muhammad Moeen Bhatti2

Home , Depigmentation, Pityriasis alba, Vitiligo

CASE REPORT

ABSTRACT Pityriasis alba is a skin disease, commonly seen in children and young adults. This case presents the ocular association of this disease in a 10 years old Pakistani male. Ocular features in this case were poliosis, tilted disc, high myopia and chorioretinal degeneration. Tilted discs and high myopia can be coincidental but poliosis and decreased pigment in retinal pigment epithelium are closely related with the hypopigmentation seen in this disease.

Key Words: Pityriasis alba. Poliosis. Vitiligo. Retina.

INTRODUCTION On examination, he was an average built young boy who Pityriasis alba is a self limiting dermatosis. It is regarded was well oriented in time and space. He was orthophoric as a manifestation of atopic dermatitis. However, non- and had hypertelorism. There was recent onset poliosis atopic individuals are also known to have this disease.1 (Figure 1), otherwise the eyelids were normal with no It can occur in any race but more problematic in dark signs of blepharitis. Autorefraction showed -12.75 DS skinned individuals. In an audit at Hamdard University with -1.75 DC at 12° in right eye and -11.5 DS with -2.00 Hospital, Karachi, the frequency of this disorder was DC at 180° in his left eye. His best corrected visual found to be very low as compared to the other acuity was 6/36 with -5.00 DS in each eye. Anterior dermatological diseases.2 About 4.9% patients had segment showed no abnormality. On dilated fundus pityriasis alba in an epidemiological study presented by examination, there were tilted discs in both eyes. Large Sharma in Indian Punjab.3 choroidal vessels were visible due to myopic chorioretinal degeneration which was also involving the Lesions of pityriasis alba are characterized by rounded, macular region. oval or irregular plaque with indistinct margins. The cause of this disease is still unknown. However, many General physical examination showed normal vital contributory factors are mentioned in the literature signs. Skin showed hypopigmented lesions on the face including, temperature, humidity, hygiene and altitude. especially around the mouth, chin and on the cheeks. No treatment is usually required and the disease is They were round or oval and margins were not well self resolved within months or a year. This case report defined. The lesions showed no signs of inflammation presents the ocular features which were found in but there was history of mild erythema prior to the association with pityriasis alba. appearance of these white patches. There was no history of eczema and asthma. There were no signs of thyroid disease, lymphoma and pernicious anaemia. CASE REPORT Chest X-ray, CBC and liver function tests were normal. A 10 years old Pakistani child came to the out-patient The patient was referred to dermatology department for department with history of decreased vision in both eyes management. Biopsy was not required for diagnosis and for 2 years. He had been prescribed glasses but the not done in this patient. Clinical features helped in compliance was poor. There was no irritation and making the diagnosis. redness in both eyes. Systemic history revealed whitish patches on the skin, especially on the face which DISCUSSION appeared 2 years back. He had two brothers and one sister and all were normal with no ocular and systemic Pityriasis is derived from a Greek word which means disease. scaling and flaking. Alba means white in Latin. The patches are not entirely depigmented in this condition.4 1 Department of Ophthalmology, Lahore Medical and Dental It is a common disorder of children and young adults and College, Lahore. there is increased occurrence in pre-adolescent children. 2 Department of Ophthalmology, Ghurki Trust Teaching Whites are more prone than blacks. Both gender are Hospital, Lahore. equally affected. In this particular case, age of the child Correspondence: Dr. Tayyaba Gul Malik, 649-N, Samanabad, was 10 years. Lahore-25. Etiology of this disease is still unknown but there is a E-mail: [email protected] common association of pityriasis alba with atopy or a Received: November 27, 2012; Accepted: March 16, 2013. strong family history of atopy. It was not elicited in this

138 Journal of the College of Physicians and Surgeons Pakistan 2014, Vol. 24 (2): 138-140 Pityriasis alba with poliosis

this particular patient and the depigmentation was not pink or brown. Ocular features in this case were poliosis, tilted disc, high myopia and chorioretinal degeneration. We could not find any of these in any case of pityriasis alba reported so far in the literature. It was tried to rule out the other causes of poliosis. Common ocular causes of poliosis are chronic 9 Figure 1: Patient with poliosis. blepharitis, sympathetic ophthalmia and uveitis. All of these conditions were absent in this patient. Systemic associations of poliosis include Vogt Koyanagi Harada syndrome, Wardenburg syndrome, vitiligo, Marfans syndrome and Tuberous sclerosis. Typical skeletal and soft tissue abnormalities associated with Marfan's syndrome were absent in this patient. Absence of adenoma sebaceum, cafe au lait spots, ash leaf spots, shagreen patches and other visceral and neurological Figure 2: Hypopigmentation around the mouth. signs of tuberous sclerosis ruled out this condition. There were no clinical features suggestive of Warden- case and also not in close family members except a history of asthma in one of his paternal uncles. burg syndrome and VKH syndrome. In vitiligo, hypopigmentation is well demarcated while the margins of There are certain possible risk factors. More common hypopigmentation in that patient were blurred. We are xerosis and mineral deficiency. Sun exposure makes searched the literature but did not find any case showing 5 these lesions more prominent. Some studies have association of poliosis with pityriasis alba. shown that it is associated with copper deficiency.6 Tilted disc and high myopia could be chance asso- In this patient, no history or clinical evidence of xerosis ciations. Pigment deficiency in the retinal pigment was found. Serum mineral analysis could not be epithelium can be either due to myopic degeneration or performed. because of the fact that number of melanosomes Three stages of this disease are identified: erythema, are deficient in the lesions of skin of pityriasis alba. scaling and hypopigmentation. Mild scaling and hypo- Literature reveals that histologically there is no signifi- pigmentation are the clinical features which are more cant difference in the number of melanocytes between commonly seen when the patients seek medical advice. the lesional and the normal skin.10 However, the number Lesions are more prominent around the mouth, cheeks and size of melanosomes are reduced in these lesions. and chin. This patient had hypopigmented lesions on the To the authors’ knowledge, this is the first report of face especially around the mouth, cheeks and chin as pityriasis alba with poliosis. Poliosis can be caused by shown in Figure 2. Scaling of the lesions could not be damage to the melanosomes which is histologically made out. It might be because of the reason that scaling evident in the literature. This decrease in the number of is more common in dry winter while hypopigmentation melanosomes might be induced by erythema which was becomes more prominent in summer. Usually no seen in the first stage of pityriasis alba. Further research treatment is required for hypopigmentation and patches on the ocular associations of this disease is required. heal with time.7 There is a large list of hypopigmented lesions of the skin REFERENCES but few are associated with the ocular manifestations. 1. Sandhu K, Handa S, Kanwar AJ. Extensive pityriasis alba in Skin depigmentation is seen in Naevus depigmentosus, a child with atopic dermatitis. Pediatr Dermatol 2004; 21: cutaneous T-cell lymphoma, vitiligo and pityriasis rosea. 275-6. Naevus depigmentosus is present at birth or before 3 2. Javed M, Jairamani C. Pediatric dermatology: an audit at years. It is a single well demarcated lesion on the trunk Hamdard University Hospital, Karachi. J Pak Assoc Derma with no ocular findings.8 There are reports indicating 2006; 16:93-6. ocular involvement in cutaneous T-cell lymphoma but 3. Sharma S, Bassi R, Sodhi MK. Epidemiology of dermatosis in this disease is associated with indolent inflammatory children and adolescents in Punjab, India. J Pak Assoc Derma response which was absent in our patient. In pityriasis 2012; 22:224-9. rosea pink, salmon pink or brown coloured patches are 4. Pinto FJ, Bolognia JL. Disorders of hypopigmentation in found on the extremities. The extremities were normal in children. Pediatr Clin North Am 1991; 38:991-1017.

Journal of the College of Physicians and Surgeons Pakistan 2014, Vol. 24 (2): 138-140 139 Tayyaba Gul Malik, Muhammad Khalil and Muhammad Moeen Bhatti

5. Jadotte YT, Janniqer CK. Pityriasis Alba revisited: perspectives logical characteristics of nevus depigmentosus. J Am Acad on an enigmatic disorder of childhood. Cutis 2011; 87:66-72. Dermatol 2006; 55:423-8. 6. Galadari E, Helmy M, Ahmed M. Trace elements in serum of 9. Kanski JJ. Clinical ophthalmology: a systematic approach. pityriasis alba patients. Int J Drmatol 1992; 31:525-6. 7th ed. Philadelphia: Elsevier Butterworth Heinemann; 2011.

7. Lin RL, Janniger CK. Pityriasis alba cutis; cutaneous medicine 10. In SI, Yi SW, Kang Hy, Lee ES, Sohn S, Kim YC. Clinical and for the practitioner. Pediatr Dermatol 2005; 76:21-4. histopathological characteristics of pityriasis alba. Clin Exp 8. Kim SK, Kang HY, Lee ES. Kim YC. Clinical and histopatho- Dermatol 2009; 34:591-7.

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