Hypopigmented Macules in a Child

The patient is a 4 1/2-year-old boy who is seen today for evaluation of hypopigmented macules on the arms and legs for less than a week. His parents first notice this four or five days ago. He has been in his usual state of health although two days ago he developed a fever to 104.7  and was seen by his pediatrician who felt it was a viral syndrome. Throat culture was negative for strep.

On examination: This is a healthy appearing child. He does have a raspy cough. He has 5 to 7 mm in diameter hyperpigmented macules scattered over the arms and legs. Some of these lesions have a so much angular outline.

The patient's mother is a neighbor who lives about a one minute walk from my house, so they walked over and I took a look.

My initial thoughts are that this may be the onset of vitiligo,  The lesions are larger than itiopathic guttate hypomelanosis; but if this occurs in children it must be very rare. 

Your thoughts will be appreciated.  Should any tests be done at this time?

Hypopigmentation in an African

The patient is a 39 yo man from Ghana.  His wife noticed these spots on his back recently.  My first diagnosis was tinea versicolor; but KOH prep showed only spores.  Is this just quiescent T.v.?  It's symmetrically distributed over upper back (no where else).  In differential diagnosis was vitiligo -- but this is incomplete hypopigmentyation (which can occur with vitiligo, but less commonly).  I suggested ketoconazole cream and a follow-up in 3 months.  If still present, may do a biopsy.
What are your thoughts?

References:

1. The utility of dermoscopy in the diagnosis of evolving lesions of vitiligo.

Thatte SS1, Khopkar US.  Indian J Dermatol Venereol Leprol. 2014 Nov-Dec;80(6):505-8.

BACKGROURD: Early lesions of vitiligo can be confused with various other causes of hypopigmentation and depigmentation. Few workers have utilized dermoscopy for the diagnosis of evolving lesions of vitiligo.

CONCLUSION: Pigmentary network changes, and perifollicular and perilesional hyperpigmentation on polarized light examination, and a diffuse white glow on ultraviolet light examination were noted in evolving vitiligo lesions. Histopathological examination was comparatively less reliable. Dermoscopy appears to be better than routine histopathology in the diagnosis of evolving lesions of vitiligo and can obviate the need for a skin biopsy. Free Full Text.

2. Dermoscopy as an ancillary tool for the diagnosis of pityriasis versicolor.

Zhou H, Tang XH, Chen MK. J Am Acad Dermatol. 2015 Dec;73(6):e205-6. (this is only reference in PubMed on T.v. and dermsocopy and it is not particularly helpful)

3. Dermatoscope--the dermatologist's stethoscope.

Lallas A, Argenziano G.  Indian J Dermatol Venereol Leprol. 2014 Nov-Dec;80(6):493-4. Full Free Text 

This is an interesting somewhat philosophical article.  The references are extensive and helpful.

Unilateral/Segmental Vitiligo in a 9-year-old boy receiving Melagenina as treatment

HPI: The patient is a 9-year-old boy who developed loss of pigmentation on the right side of his face over a 3-month-period. The depigmentation of the skin progressed rapidly with no antecedent eruption, redness or trauma. There was no history of exposure to a chemical or irritant prior to depigmentation of the skin.

No medical history of hypothyroidism or other medical conditions.  No family history of vitiligo or autoimmune diseases. He often spends 2 to 6 hours in the sun playing outside only beginning to wear sunscreen recently. 

Diagnosis:  He appears to have a segmental or unilateral vitiligo.

He lives in Cozumel, Quintana Roo, Mexico and has been evaluated by a dermatologist locally who confirmed the diagnosis clinically.  No biopsy was obtained.

Labs: TSH, complete blood count and chemistry panel were normal.

Prior/Current Treatment:  Melagenina solution

Since the patient is a citizen of Mexico, he and his family were able to travel freely to Cuba and obtained an appointment in the Vitiligo clinic evaluation and treatment after a 6-month wait. Their first visit to Cuba was in August, and they are expected follow-up in 6 months. He was given Melagenina solution to be applied twice a day to the depigmented areas of skin. Melagenina solution can only be obtained in Cuba at this time.  It is derived from placental extract that is mixed with an alcohol solution. He will return to Cuba in February 2016 for a follow-up visit and to obtain more Melagenina.

Images:

 

His mother has noticed some repigmentation of the treated areas.  The pictures shown are after using the treatment for 4 months.

Second Opinion in USA and Plan:

We recommended adding tacrolimus (Protopic 0.1%) ointment and a low-dose steroid such as mometasone furoate cream to his Melagenina treatment regimen to be applied twice a day. The patient was counseled on the importance of using a titanium and zinc oxide waterproof sunscreen on the face to prevent further darkening of the surrounding area and to protect the areas of depigmentation.

Discussion:

Vitiligo is a common skin disorder affecting about 1 to 2% of the world population. It commonly affects children and can be seen in different patterns.  This patient appears to have a unilateral or segmental pattern but not necessarily dermatomal. 

It has been shown that segmental vitiligo in children is relativley common and less frequently associated with systemic autoimmune diseases or endocrine disorders.

Treatment in the USA and Mexico includes using narrow band UVB phototherapy or psoralen with UVA phototherapy as well as topical low-dose steroids and tacrolimus combinations. Narrow band UVB phototherapy is considered one of the most efficacious treatments and can be used alone and in combination with topical steroids and tacrolimus. Some patients are also treated with the excimer lasers and have undergone melanocyte transplants. Melagenina or placental extracts are not used currently.

In the General de Mexico hospital, up to 50 cases of vitiligo are seen per day.  Many efforts are being made to increase awareness about vitiligo. One controversial issue in Mexico has been the exploration of naturalist physician care and unresearched treatments options. As we are aware, this is a consideration in the U.S. as well. Although the medical community wants to be open to new ideas involving topical and oral nutritional and botanical substances, in Mexico the concern is that patients will use their limited financial resources on unsubstantiated treatments. Phototherapy clinics treat vitiligo patients in the larger cities of Mexico, but unfortunately many patients, including this patient, could not travel regularly to these established clinics due to financial and transportation limitations.

1)   How safe, well regulated and efficacious is the Melangenina solution in the treatment of vitiligo? Should this be something explored more for patients in the USA?

2)   Should the patient inform the physicians in Cuba that they will be adding other topical medications to the regimen?

Out of respect to the Cuban dermatologists, we encouraged them to inform the clinic that a second opinion was sought out and new medications were started.  The patient and his family were unsure if the treatment with Melagenina was part of a clinical trial.

3)   Should we consider oral minipulse therapy with methylprednisolone? 

Although there are relapses and other considerations with oral steroid use in children, a few case reports and clinical trials have shown some benefits.

 

Lo, Yuan-Hsin, Gwo-Shing Cheng, Chieh-Chen Huang, Wen-Yu Chang, and Chieh-Shan Wu. "Efficacy and Safety of Topical Tacrolimus for the Treatment of Face and Neck Vitiligo." The Journal of Dermatology 37.2 (2010): 125-29. Web.

 http://onlinelibrary.wiley.com/doi/10.1111/j.1346-8138.2009.00774.x/full

Majid, Imran et al. “Childhood vitiligo: response to methylprednisolone oral minipulse therapy and topical fluticasone combination.” Indian Journal of Dermatology 54.2 (2009): 124–127. PMC.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2807150/ 
 

 Shrestha, S., AK Ha, and DP Thapa. "An Open Label Study to Compare the Efficacy of Topical Mometasone Furoate with Topical Placental Extract versus Topical Mometasone Furoate with Topical Tacrolimus in Patients with Vitiligo Involving Less than 10% Body Surface Area." Nepal Medical College Journal 16.1 (2014): 1-4. Web.

Xu, Aie, Dekuang Zhao, and Yongwei Li. "Melagenine Modulates Proliferation and Differentiation of Melanoblasts." International Journal of Molecular Medicine Int J Mol Med (2008): n. pag. Web.

 http://www.spandidos-publications.com/ijmm/22/2/193

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