Sunday, January 27, 2008

Question from Iraq












Dear Colleagues,

Pityriasis alba, a disease of young children, is a superficial dermatitis which often presents in two stages: first the erythematous stage which over time developes into (the second) a whitish stage. In Iraq, we see, not infrequently, children with pityriasis alba-like patches that change over time into true vitiligo and then progress and spread to vitiligo in other parts. Many of these patients have a positive family history of vitiligo. At the initial visit it is sometimes is very difficult to tell parents whether their children have vitiligo or not and we fall into big dilemma.

I see many of these and treat them as vitiligo. They respond as well as as those we treat for pityriasis alba.

Question: I would like to ask our colleagues whether you have any similar observation? I intend to initiate a study about this problem shortly.

Khalifa Sharquie

Note: The current case on the classic VGRD site is also from Iraq. Please view it, too.
Baghdad, Iraq

12 comments:

  1. We have a lot of cases of pityriasis alba in Cyprus but as far i know without connected with vitiligo as well. Usually appearance in summer(more darker skin) and disappear in winter. As for a treatment usually i treat only topical with Fucicort(morning) and Elidel(evening). Some authors believes that etiology of PA is streptococcal infection. I am curious to listen another opinions about treatment and connect with vitiligo in PA.

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  2. Pityriasis alba is usually seen in atopic children and classically the picture differs from vitiligo in the appearance under Wood's light. It's my impression that with P.a. the biopsy would show a decrease of melanin in melanocytes, while in vitiligo, special stains show a decrease number of melanocytes. A prospective study would show whether P.a. transitions into vitiligo. I checked Medline and there are no references -- so you may be on to something here.

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  3. Dear Dr. Sharqui, you always come up with something interesting. Yes, sometimes PA resembles vitiligo as hypopigmentation stands out in the pigmented skin. The parents of children with PA also have similar concerns. I clinically diagnose PA by its indistinct border, hypopigmentation, a subtle scale, and above all its non-periorificial location. But I agree with you that we should keep more suspicious cases of PA under observation for some time.

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  4. amit pandyaJanuary 28, 2008

    This could be a Koebner phenomenon in a patient who has a propensity for vitiligo. In other words, these patients are going to develop vitiligo anyway. The first manifestation appears in a site associated with inflammation, in this case, pityriasis alba. I have seen this occur with pityriasis alba, seborrheic dermatitis, and especially with trauma of the hands in patients who work in construction, hand tools, landscaping, etc.

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  5. Dr Parveen K Gupta from Faridkot ,INDIA writes :
    We have seen many cases of Pityriasis Alba but none of them has progressed to Vitiligo.The differential diagnosis lies in Wood's light examination.In P.Alba it is creamy yellow whereas in vitiligo it is white. You should try topical steroids with antifungal in the early stages. It improves most of the cases.

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  6. Samer A DhaherJanuary 29, 2008

    Dear sir..the sequense of event in the present may be explained partly by a koebnerization phenomena in which vitiligo occured at the site of previous inflammation(pity. alba),or by the fact that early stage of vitiligo(the so called stage one vitiligo) may closely mimic pity. alba & what has been observed initially on the face of the child was simply stage 1 vitiligo.Therefore, the use of Woods light is strongly recommended to discreminate between the 2 diseases

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  7. Khalifa SharquieJanuary 30, 2008

    Great thanks to my colleagues for their fruitful comments; but I would like to make the following points:
    1-Vitiligo is inflammatory skin Ds as shown by my studies and other studies
    2-Vitiligo might start initially as itchy dermatitis or urticarial like rash before progressing into leukoderma
    3-vitiligo stage one depigmentation is easilly distinguished from pityriasis alba clinically and by histological appearance
    4.Pityriasis alba should be easily diagnosed clinically even by trainee in dermatology.So it could not be confused with other causes of hypopigmentations
    Accordingly I have no doubt that some cases of pityriasis alba progress to vitiligo especially in children with genetic predisposition. So please keep close look into this new observation
    khalifa

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  8. Samer A DhaherJanuary 31, 2008

    Dear sir..my former comment was submitted to suggesta comprehensive explanation to what happend here..but not to deny it..yes I do agree with the pro.Sharquie observation that some cases of PA may progress to an overt vitiligo,me & my coulegues come across few cases..the quetion is what the mechanism behind..we hope that the forcoming study proposed by prof. Sharquie will provide the answer..we always keep learning from him..

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  9. khalil I HamdiFebruary 02, 2008

    Dear prof.sharquie..I have seen 2 similar cases of PA that progressed to vitiligo later.. this could happened particularly in genetically predisposed patients.. please go ahead in your study to confirm this valuable observation

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  10. Abbas AlshammariFebruary 04, 2008

    Many thanks for presenting this big dilemma at least in the region we live (Middle east). Pityriasis alba (PA) and early vitiligo may simulate each other especially in cases that PA lacks its usual scales. As described by Prof. Sharqiue, sometimes it is very embarrassing to tell the family a diagnosis of vitiligo as it is one of the disfiguring disorders particularly in colored. I have noticed that the problem commonly arises shortly after starting topical therapy and when the scales disappear leaving shiny and more whitish color than previously. Unifying concepts are usually welcomed but not always applicable. PA & vitiligo are well known separate clinical entities and most probably the cases recognized as PA and with time changed into vitiligo were originally cases of early vitiligo but interpreted as PA or the diagnosis was pretended because of:
    1. Associated irritation by soap, water or weather changes resulting in scaliness of skin.
    2. Borderline cases between PA & early vitiligo on the face should be dealt with cautiously. In my opinion; to tell the family a case of PA that needs follow up is much better than to settle the diagnosis of vitiligo and subject the patient and family to great stress which affects the outcome adversely.
    Finally I am looking forward to read a short account about how to deal with cases of PA and questionable cases according to the experience of my teacher Prof. Sharqiue.

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  11. In my opinion P.Alba is an entirely different entity,it is a type of endogenous eczema, seen on dry skin ,more common in winter.It responds very well to emollient and topical mild steroids.

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  12. as for as concern with vitiligo in children it is not related with the war in the Iraq.Vitiligo is related with the irregularity of the immune system of homan beign.
    for further detail about click here Vitiligo

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