Sunday, September 21, 2008

Hypopigmentation in an African Child

Katie Ratzan, a third year Dartmouth Medical School student serving as a Schweitzer Fellow at the Schweitzer Hospital in Gabon, Africa, would like help and advice.
" I would like to ask your help with a six year old girl who presented to our clinic at the Hopital Schweitzer, with her father & aunt. The child has a recent onset of hypopigmentation of the left side of her face & neck. As of six to seven weeks ago, her skin was entirely normal. This change in skin color progressed over the past six weeks. It is asymptomatic. She has had no constitutional symptoms. She was not sick during the months/weeks prior to the color change, did not take any medications prior to the skin change, did not travel, did not have an accident with any sort of chemical, does not use anything on her face (i.e. cremes, etc.). No one else around her has anything like this. No one else around her is sick. She's never had this before. She now puts some sort of indigenous healing/darkening creme on the spots on the back of her neck, which is why that is darker than the areas of her face.

By history, this started on her cheek and moved toward her nose. It stops abruptly at midline. It has since spread to her neck and scalp. It's macular/patch-like depending on the confluence of abutting lesions. There is no involvement of mucous membrance (mouth & vagina are normal). She has no trouble with vision, taste, hearing, and her neuro exam (my brief version of it which essentially only tested sensation and gross motor) was normal.





Questions from Katie:
1. Does anyone think this is anything other than vitiligo?
2. Is this segmental vitiligo, and if so what special significance does this have?
3. What therapy would be appropriate for a child like this in this setting?
4. What is known of the psychological and social implications of such hypopigmentation in a girl in this setting?


Thank you,
Katie

12 comments:

  1. I also think this a segmental Vitiligo with trichrome’s phenomenon. Trichome’s phenomenon is means that there may be different shades of brown in a vitiligo patch. Usually this phenomenon is present in more darker skin. You can see more clear Trichome’s phenomenon in your second photo of your case.

    You can use different treatment in Vitiligo but I don’t know which of them it’s available in your country.
    Anyway I will give you the most populars.
    In early stage of Vitiligo you can use topical steroid. Also in early stage you can use a microinjection of steroid with Pentoxifylline.
    Another variant in early stage of Vitiligo is a topical pimecrolimus, tacrolimus or calcipotriol with Narrowband UVB phototherapy.
    If those treatments are not effective then the last chance is a surgical treatment (skin graft transplantation of melanocyte).

    Interesting case.Thanks Katie.

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  2. Thank you for your comments! That is very helpful. How would this look different/present differently if it were dermal onchoceriasis? Thanks.

    Katie

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  3. Hi,
    I'm a DMS grad and a dermatology resident at the University of Minnesota, who happens to be doing a pediatric dermatology rotation right now with Dr. Joseph Morelli at UCHSC in Colorado. We both looked at the case and posts this morning and also agree that it looks like segmental vitiligo. It is probably too well-demarcated to be dermal onchocerciasis. If NBUVB isn't available we'd recommend high-potency topical steroids to start with (an exception to using strong topical steroids on the face). It is extremely difficult to treat. Good luck!

    Christine Weinberger

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  4. I agree that this is segmental vitiligo. I would begin with clobetasol at night one week on, one week off, with 15 minutes of noonday sun daily. I would keep the clobetasol away from the eyes. blister or punch transplants can be tried and work well in segmental vitiligo, but she will need a lot.

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  5. Ashok K. SharmaSeptember 22, 2008

    I would agree with the diagnosis of Segmental Vitiligo for the case. I have had some good results with potent topical steroids and more recently with Excimer Laser. But favorable response to any therapy is rather an exception than a rule in this type of vitiligo. Personally I have not used skin grafting for any of my patients; I tend to presume that depigmentation would recur in the grafted skin in such cases.

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  6. Thanks again for everyone's comments. I am seeing the patient and her aunt again this week and will see what we have available here for treatment (if it's any indication, we've been out of ibuprofen for at least 5 weeks now...). I will put up more cases as they come along.

    Katie

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  7. This is a difficult case to treat. I agree witht the comments by Dr Stelios that this is segmental vitiligo. NB-UVB phototherapy with eye shield would be a useful therapeutic option. I would also use topical tacrolimus ointment alternating with topical calcipotriol daily. Perhaps weekend topical clobetasol can be added as an adjunct.

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  8. Typical most resistant type of vitiligo(dematomal type),I treat few cases by topical tincture iodin 10%(proved by sir Ksharquie)followed by(1hour)topical potent steroid at night and topical tacrolimus at morning for 3-6 months duration in addition sun avoidance by sun screen might give good result.
    firas altamimi

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  9. DR MANISH PAHWAOctober 06, 2008

    Hi
    To my mind it is segmental vitiligo. Having dealt with afew such patients, I have realized that later in life they have white hair even outside the lesion, but in the same segment.Thus I feel, we should treat this treatable form of vitiligo with fluticasone, tacrolimus and methoxsalen topically. after waiting for 6 months, we should do blister grafting or smash grafting for the remaining areas,
    DR MANISH PAHWA
    MD DNB (INDIA)

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  10. interesting case i think tis is a very resistant type of vitiligo to deal with steroids. till the lesions are stable it is better to use topical or even oral steroids or other immunomodulators,after that punch vitiligo grafting with narow-band puva exposure would give good results.

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  11. Hi Katie,

    Thanks for posting this interesting case.

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  12. YES.
    THE DIAGNOSIS IS MOST OBVIOUS.
    AFTER 4 TO 6 MONTHS TRIAL SHE S'D BE OFFERED MICRO PUNCH GRAFTING OR SUCTION BLISTER GRAFT WHICH GIVE EXCELLENT RESULTS

    DR NAVIN MODI,INDIA

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