Pityriasis Alba Versus Vitiligo

Journal of the Saudi Society of Dermatology & Dermatologic Surgery (2013) 17,51–54

King Saud University Journal of the Saudi Society of Dermatology & Dermatologic Surgery www.ksu.edu.sa www.jssdds.org www.sciencedirect.com

ORIGINAL ARTICLE Pityriasis alba versus vitiligo

Khalifa E. Sharquie a,*, Adil A. Noaimi b,1, Haitham M. Salmo c,2 a Scientiﬁc Council of Dermatology & Venereology-Iraqi Board for Medical Specializations, Department of Dermatology & Venereology, College of Medicine, University of Baghdad, Baghdad, Iraq b Department of Dermatology and Venereology, College of Medicine, University of Baghdad, Baghdad, Iraq c Department of Dermatology and Venereology, Baghdad Teaching Hospital, Baghdad, Iraq

Received 28 October 2012; revised 9 May 2013; accepted 14 May 2013 Available online 14 June 2013

KEYWORDS Abstract Objective: To evaluate the factors that support the hypothesis in favor that pityriasis Pityriasis alba; alba might progress into vitiligo. Vitiligo; Patients and methods: This observational case series study was done in Department of Derma- Iraqi patients tology-Baghdad Hospital during January 2008–September 2009. History and examination were done. Koebner’s phenomenon was carried out for all patients on the hidden areas by blunt object, and watched for 1–3 months to observe the appearance of leukoderma. Results: One hundred thirty-four patients with pityriasis alba were included, their ages ranged from 2 to 15 (7.9 ± 3.3) years, family history for vitiligo was positive in 26 (19.4%) patients. Nine- teen (14.17%) patients had coexistence of pityriasis alba and vitiligo lesions and showed positive wood’s light examination for vitiligo, 11 of 19 (57.89%) patients had positive family history for vitiligo. Only 32 (23.88%) of 134 patients had continued the study and follow-up, 14 (43.75%) patients, showed progression of their original pityriasis alba lesion into vitiligo. Also, 11 (34.35%) had positive Koebner’s phenomenon and 10 (31.25%) patients had positive family of vitiligo.

* Corresponding author. Address: Scientiﬁc Council of Dermatology and Venereology-Iraqi Board for Medical Specializations, Department of Dermatology and Venereology, College of Medicine, University of Baghdad, Medical Collection Ofﬁce, P.O. Box 61080, 12114 Baghdad, Iraq. Tel.: +964 7901468515; fax: +964 1 5372193. E-mail addresses: [email protected] (K.E. Sharquie), adilnoai- [email protected] (A.A. Noaimi), [email protected] (H.M. Salmo). 1 Tel.: +964 7901751642. 2 Tel.: +964 7901783855. Peer review under responsibility of King Saud University.

Production and hosting by Elsevier

2210-836X ª 2013 Production and hosting by Elsevier B.V. on behalf of King Saud University. http://dx.doi.org/10.1016/j.jssdds.2013.05.002 52 K.E. Sharquie et al.

Conclusions: This study conﬁrmed that pityriasis alba might change into vitiligo by following ﬁndings: close association between pityriasis alba and vitiligo, high positive family history of vitiligo among patients with pityriasis alba, high percentage of pityriasis alba progressed to vitiligo and Koebner’s phenomena had a high frequency among patients with pityriasis alba. ª 2013 Production and hosting by Elsevier B.V. on behalf of King Saud University.

1. Introduction patch. So, the diagnosis for PA and vitiligo was made by: history, clinical features, Wood’s lamp and histopathological Pityriasis alba(PA) is a common benign condition mainly affect- examinations. ing the head and neck regions of preadolescent children, more Koebner’s phenomenon was done for all patients on the noticeable in darker skin types and there is no gender or skin type hidden area (back or upper arm) by blunt object, and watched predilection (Wolff et al., 2008), occurs predominantly in chil- for 1–3 months to observe the appearance of leukoderma. dren between the ages of 3 and 16 years (Holden and Berth- Shave biopsies were taken from 9 patients during the follow Jones, 2006). The condition is more frequently seen in children up period (leukoderma stage) and stained for H&E and Fon- and adolescents than in adults, it has been reported in 40% of tana–Masson stains for histopathological study. Egyptian and 38.22% of Iraqi children. Mohammed (1994), Formal consent of the parents of the patients was reported but is more common among males in Iraq (Mohammed, 1994). after full explanation about the target of this study, the nature The lesions are frequently limited to the face, but the neck, of the disease, course, and treatment, follow up, prognosis and arms, and shoulders can also be involved (Zaynoun et al., the need for pre and post treatment photographs. Also, ethical 1983; Kamaldeep et al., 2004). approval was performed by the Scientific Council of Dermatol- The etiology remains not well elucidated but PA has been ogy and Venereology-Iraqi Board for Medical Specializations. commonly characterized as a mild form of atopic dermatitis All patients were photographed by Sony-Cyber Digital, high (Wolff et al., 2008). Excessive, unprotected sun exposure as sensitivity, 16.1 megapixels, 5· optical zoom camera in each well as hygienic habits (frequent bathing and hot baths) are visit, in the same place with fixed illumination and distance. strongly related to the development of PA (Wolff et al., 2008). Follow up of the patients was done monthly to observe any Microorganisms such as Pityrosporum, Streptococcus, clinical changes in the appearance of patches and any progres- Aspergillus and Staphylococcus have been suggested as causal sion to vitiligo was noticed, also patients who observed any factors, but none has been confirmed. Other contributory fac- change at the site of scratching (kobner’s phenomenon)was tors, such as temperature variations, relative air humidity, alti- asked to attend for examination. tude and excessive sunlight exposure have also been implicated During the subsequent visit wood’s lamp examination was (Zaynoun et al., 1983; Blessmann Weber et al., 2002). done for all the body with close concentration at the site of pit- During our daily clinical practice, we observed close associ- yriasis alba. ation between pityriasis alba and vitiligo and many patients with pityriasis alba might change into vitiligo. 3. Results Accordingly, the aim of present study was to evaluate the factors that support the hypothesis in favor that PA might pro- A total of 134 patients with PA were seen. The ages of patients gress into vitiligo. ranged from 2 to 15 years with a mean ± SD of 7.9 ± 3.3 years, 81 (60.44%) males and 53 (39.55%) females. 2. Patients and methods Family history for vitiligo was positive in 26 (19.4%) patients. The face was found to be affected in 75 (55.97%) patients, chest in 11 (8.2%) patients, back in 6 (4.47%) patients and This observational case series study was carried out in the other site with or without the face in 57 (42.53%) patients. Department of Dermatology and Venereology – Baghdad The lesions were multiple in 120 (89.55%) cases while it was Teaching Hospital for a period extending from January 2008 single in 14 (10.44%) patients. to September 2009. The types of lesions were: scaly erythematous patches in 14 One hundred thirty-four patients with piytriasis alba were (10.44%), scaly hypopigmented patches in 59 (44.02%), smooth included in this study. All patients had localized pityriasis alba hypopigmentd patches in 49 (29.85%) and combination of dif- while only four patients had wide spread disease. History was ferent stages was found in 12 (8.95%) patients. Of the total cases, taken from each patient regarding all relevant points related to 19 (14.17%) patients had coexistence of PA and vitiligo lesion vitiligo and PA. Inclusion criteria were only patients with typ- and showed positive wood’s lamp examination for vitiligo; 11 ical clinical features of piytriasis alba with their different types of 19 (57.89%) patients had positive family history of vitiligo. were included in this study. While all cases with typical clinical The size of patches ranged from 0.20 to 004 cm2. It was ob- pictures of vitiligo with their different stages of depigmenta- served that patches in patient with vitiligo were well demar- tions were excluded from the present work. cated and the loss of pigment was even while the patches in Physical examination was carried out including: clinical PA were not well demarcated and the loss of pigment was appearance of the patches, site, edges, size and the degree of gradual from center toward the periphery: it means that the pigmentation. This was confirmed by Wood’s lamp to assess leukoderma was more intense at the center (Fig. 1). the degree of pigmentation loss. Thirty-three (24.62%) patients had exacerbation of PA dur- The clinical picture was recognized by three clinical stages: ing summer time (sun exposure) and 14 (10.44%) patients had scaly erythematous, scaly hypochromic, smooth hypochromic Pityriasis alba versus vitiligo 53

inside the epidermis and dermis in the lesional area, while it was present at surrounding normal skin (Fig. 2). No other histological changes were observed.

4. Discussion

Recently we are facing a great challenge regarding distinction criteria of differentiation between pityriasis alba from early vitiligo or whether pityriasis alba progresses to vitiligo, or other post-inflammatory hypo-pigmentation. So the target of the present work is a trial to make a clear distinction between vitiligo and PA and to study the close association between these two diseases. The criteria for distinction of pityriasis alba from early vitiligo include scaly lesion, indistinct margin, positive or negative wood’s lamp and negative family history of vitiligo. In the present study, 43.75% of the patients had progressed into ordinary vitiligo and this was confirmed by high positive family history of vitiligo, positive Koebner’s phenomenon and complete absence of melanin by histopathological study. Accordingly there is a high risk factor among patients with PA to change into vitiligo. Both PA and vitiligo are inflammatory hypopigmented skin diseases (MacMillan, 1971; Sharquie, 1982; Sharquie et al., 2004) but in PA the loss of pigmentation is usually partial and starts at the center gradually extending toward to the periphery while in vitiligo the loss of pigmentation is usually complete and well demarcated from the surrounding skin. In addition, in both diseases the condition might start as scaly erythematous dermatitis like picture which might simulate each other (MacMillan, 1971; Sharquie, 1982, 1988, 2004). In conclusion, the present work had showed 4 findings in favor of pityriasis alba might change into vitiligo; first genetic susceptibility as confirmed by strong positive family of vitiligo (31.25%) among patients with pityriasis alba, second the close association between pityriasis and vitiligo in the same patients (14.17%), third a high percentage (43.75%) of pityriasis alba progressed to vitiligo, and fourthly, the high association of pityriasis alba and Koebner’s phenomena (34.35%).

Figure 1 (A) Ten years Male child with patches of pityriasis alba versus vitiligo. (B) Eleven years Male child with patches of pityriasis alba versus vitiligo. a habit of excessive wash. Fifteen (11.19%) patients had reliev- ing of their condition during winter. Only 32 (23.88%) of 134 patients had continued the study and follow-up, only 14 (43.75%) patients, 9 males and 5 females, showed progression of their original pityriasis alba lesion into vitiligo. Also, 11 (34.35%) patients had positive Koebner’s phenomenon and 10 (31.25%) patients had positive family of vitiligo. Histopathological study of 9 biopsies of leukoderma showed; H&E stain appeared as normal skin histology while Figure 2 Fontana stain showed complete absence of melanin Fontana–Masson stain showed complete absence of melanin inside the epidermis and dermis in the lesional area, while it was present at surrounding normal skin. 54 K.E. Sharquie et al.

Funding/support Kamaldeep, S., Sanjeev, H., Kanwar, A.J., 2004. Extensive pityriasis alba in a child with atopic dermatitis. Pediatr. Dermatol. 21, 275–276. MacMillan, A., Rook, A.J., 1971. Vitiligo with raised rim in atopic This study was supported by Iraqi Board of Medical subjects. BJD 85, 491. Specializations. Mohammed, T.Y., 1994. Hypopigmented Skin Disease in Infants and Children Diploma Thesis. Medical College, University of Baghdad. Disclosure Sharquie, K.E., 1982. The Histology and Immunopathology of vitiligo. University of Sheffield, England. Sharquie, K.E., 1988. Stages of depigmentation in vitiligo. Iraqi Med. This study was an independent study and not funded by any J. 36, 47–50. drug companies. Sharquie, K.E., Mehenna, S.H., Naji, A.A., Al-Azzawi, H., 2004. Inflammatory changes in vitiligo: stage I and II depigmentation. References Am. J. Dermatopathol. 26, 108. Wolff, K., Goldsmith, LA., Katz, SI., Gilchrest, BA., Paller, AS., Leffell, DJ., 2008. Hypomelanoses and hypermelanoses. In: Fitz- Blessmann Weber, M., Sponchiado de Avila, L.G., Albaneze, R., 2002. patrick’s Dermatology in General Medicine, Seventh ed. Springer, Pityriasis alba: a study of pathogenic factors. JEADV 16, New York, pp. 624–625, 73. 463–468. Zaynoun, S.T., Aftimos, B.G., Tenekjian, K.K., 1983. Extensive Holden, C.A., Berth-Jones, J., 2006. Eczema, lichenification, prurigo pityriasis alba: a histological histochemical and ultra structural and erythroderma. In: Burns, T., Breathnach, S., Cox, N. (Eds.), study. BJD 108, 83–90. Rook’s Textbook of Dermatology. Blackwell Publishing, Oxford, pp. 37–38.