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Pityriasis Alba Differential Diagnoses

  • Author: Sarah Sweeney Pinney, MD; Chief Editor: Dirk M Elston, MD  more...
 
Updated: Apr 08, 2016
 
 

Diagnostic ConsiderationsNevus depigmentosusPigmenting pityriasis albaExtensive pityriasis albaPsoriasisTinea versicolorVitiligoProgressive and extensive hypomelanosisLeprosyMycosis fungoidesDelusional tineaNummular eczema

The differential diagnosis of pityriasis alba includes the following:

  • Hypopigmentation
  • Nevus depigmentosus
  • Pigmenting pityriasis alba
  • Extensive pityriasis alba
  • Psoriasis
  • Tinea versicolor
  • Vitiligo
  • Progressive and extensive hypomelanosis
  • Leprosy
  • Hypopigmented mycosis fungoides ( cutaneous T-cell lymphoma) [25]
  • Delusional tinea
  • Nummular eczema
  • Pityriasis rosea
  • Progressive macular hypomelanosis
  • Eruptive hypomelanosis associated with viral syndromes [26]
  • Seborrhea
  • Tinea corporis
  • Discoid eczema
  • Nevus anemicus
  • Postinflammatory pigmentary alteration
  • Atopic dermatitis
  • Contact dermatitis
  • Ash-leaf macules of tuberous sclerosis

Any inflammatory process that involves the skin, such as contact dermatitis, can leave areas of hypopigmentation upon healing. This may occur in other disorders as well, including fungal diseases (eg, tinea versicolor) and idiopathic disorders (eg, vitiligo), or may result from previous inflammatory conditions (ie, postinflammatory pigmentary alteration).

The most common disorders of hypopigmentation in children are pityriasis alba, vitiligo, nevus depigmentosus, and tinea versicolor.

Hypopigmentation may also result as a adverse effect of medications such as retinoic acid, benzoyl peroxide, and topical steroids.

Nevus depigmentosus is a stable congenital leukoderma. The localized form this condition must be distinguished from an ash leaf spot, the earliest cutaneous manifestation of tuberous sclerosis, whereas the systematized form may be confused with hypomelanosis of Ito, another neurocutaneous disorder.

Nevus depigmentosus tends to occur on the trunk, is segmental in distribution, and does not change in size or number over time.

This condition seems to be a variant of classic pityriasis alba and shows a strong association with dermatophyte infection, especially tinea capitis. It may be related to lichenoid melanodermatitis. The characteristic morphology of pigmenting pityriasis alba includes a central zone of bluish hyperpigmentation surrounded by a hypopigmented, slightly scaly halo of variable width. Patients display lesions primarily on the face.

Extensive pityriasis alba is differentiated from the classic form by the widespread and symmetrical involvement of the skin, the absence of a preceding inflammatory phase, a higher female-to-male ratio, and, histologically, the absence of spongiosis.[4] Lesions are less erythematous and less scaly in the extensive variant, as well as asymptomatic, more persistent, and more frequently seen on the trunk and less on the face.[5]

In older children and adults, the early erythematous lesions of pityriasis alba may be mistaken for psoriasis; however, the distribution, lack of psoriatic scales, and sparing of scalp, elbows, and knees exclude this diagnosis.

The lesions of tinea versicolor favor the upper trunk of adolescents. Potassium hydroxide examination of the associated scales reveals hyphal and yeast forms of Malassezia furfur.

Vitiligo is an acquired, progressive disorder, in contrast to nevus depigmentosus, which is a stable congenital leukoderma. The face is a common site for vitiligo, but the distribution is most commonly around the eyes or mouth, and, in contrast to pityriasis alba, the pigment loss is complete.

Widespread cases overlap with a condition termed progressive and extensive hypomelanosis.[4] This disorder occurs mainly in women aged 18-25 years, with progressive development of round, pale, coalescent macules mainly on the back that are unresponsive to therapy but spontaneously regress within 3-4 years.[27]

Leprosy must be considered in arid regions, including areas with armadillo exposure in the United States. In particular, association with the 7-banded armadillo in the southern United States has been described.

This is of particular concern for lesions that are atypical in any way, including lesions that are persistent or symptomatic or that change color or shape

Delusional disorders may result in chronic postinflammatory hypopigmentation changes; it may be possible for such lesions to resemble those of pityriasis alba

This condition is intensely pruritic.

 
 
Contributor Information and Disclosures
Author

Sarah Sweeney Pinney, MD Assistant Professor, Department of Dermatology, University of Texas Medical School at Houston

Sarah Sweeney Pinney, MD is a member of the following medical societies: American Academy of Dermatology, Texas Dermatological Society, Texas Medical Association, Women's Dermatologic Society

Disclosure: Nothing to disclose.

Coauthor(s)

Ronald P Rapini, MD Professor and Chair, Department of Dermatology, The University of Texas MD Anderson Cancer Center; Distinguished Chernosky Professor and Chair of Dermatology, Professor of Pathology, University of Texas McGovern Medical School at Houston

Ronald P Rapini, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Society for Investigative Dermatology, Texas Medical Association

Disclosure: Received royalty from Elsevier publishers for independent contractor; May receive consulting fee from FDA panel for consulting in future, since I am on one of their committees, but at this time so far have received zero from FDA.

Rashid M Rashid, MD, PhD Director, Mosaic Clinic Hair Transplant Center of Houston

Rashid M Rashid, MD, PhD is a member of the following medical societies: American Academy of Dermatology, Texas Medical Association, Texas Dermatological Society, International Society of Hair Restoration Surgery, Council for Nail Disorders, Houston Dermatological Society

Disclosure: Nothing to disclose.

Fadwah M Abdallah, RPh Assistant, Mosaic Clinic Hair Transplant Center of Houston

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Acknowledgements

Mohsin Ali, MBBS, FRCP, MRCP Consulting Staff, Department of Dermatology, Amersham General Hospital, UK

Disclosure: Nothing to disclose.

David F Butler, MD Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Kevin P Connelly, DO Clinical Assistant Professor, Department of Pediatrics, Division of General Pediatrics and Emergency Care, Virginia Commonwealth University School of Medicine; Medical Director, Paws for Health Pet Visitation Program of the Richmond SPCA; Pediatric Emergency Physician, Emergency Consultants Inc, Chippenham Medical Center

Kevin P Connelly, DO is a member of the following medical societies: American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association

Disclosure: Nothing to disclose.

Mark A Crowe, MD Assistant Clinical Instructor, Department of Medicine, Division of Dermatology, University of Washington School of Medicine

Mark A Crowe, MD is a member of the following medical societies: American Academy of Dermatology and North American Clinical Dermatologic Society

Disclosure: Nothing to disclose.

Pamela L Dyne, MD Professor of Clinical Medicine/Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center

Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Dirk M Elston, MD Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Mark W Fourre, MD Program Director, Department of Emergency Medicine, Maine Medical Center; Associate Clinical Professor, Department of Surgery, University of Vermont School of Medicine

Disclosure: Nothing to disclose.

Dara A Kass, MD Clinical Assistant Instructor, Department of Emergency Medicine, State University of New York Downstate Medical Center, Kings County Hospital

Disclosure: Nothing to disclose.

Reza Keshavarz, MD

Disclosure: Nothing to disclose.

Mark G Lebwohl, MD Chairman, Department of Dermatology, Mount Sinai School of Medicine

Mark G Lebwohl, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Amgen/Pfizer Honoraria Consulting; Centocor/Janssen Honoraria Consulting; DermiPsor Honoraria Consulting; GlaxoSmithKline Honoraria Consulting; HelixBioMedix Honoraria Consulting; Novartis Honoraria Consulting; Ranbaxy Lectures; Can-Fite Biopharma Honoraria Consulting; DermaGenoma Honoraria Consulting; Biosynexus Honoraria Consulting

Sohail Mansoor, MBBS, MSc Dermatologist and Lead Physician in Dermatologic Surgery, Department of Dermatology, Barnet Hospital, UK

Sohail Mansoor, MBBS, MSc is a member of the following medical societies: American Academy of Anti-Aging Medicine, American Academy of Dermatology, American Society for Dermatologic Surgery, Royal College of Physicians and Surgeons of Glasgow, and Royal College of Physicians of the United Kingdom

Disclosure: Nothing to disclose.

Andrew C Miller, MD Fellow, Critical Care Medicine Department, National Institutes of Health; Fellow, Department of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh Medical Center

Andrew C Miller, MD is a member of the following medical societies: American College of Emergency Physicians and Society of Critical Care Medicine (USA)

Disclosure: Nothing to disclose.

Christen M Mowad, MD Associate Professor, Department of Dermatology, Geisinger Medical Center

Christen M Mowad, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, and Phi Beta Kappa

Disclosure: Nothing to disclose.

David A Peak, MD Assistant Residency Director of Harvard Affiliated Emergency Medicine Residency, Attending Physician, Massachusetts General Hospital; Consulting Staff, Department of Hyperbaric Medicine, Massachusetts Eye and Ear Infirmary

David A Peak, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine, and Undersea and Hyperbaric Medical Society

Disclosure: Pfizer Salary Employment

Nicole Sakka, MBBS Foundation Year 2, Royal Liverpool and Broadgreen University Hospital, Liverpool, UK

Disclosure: Nothing to disclose.

Robert A Schwartz, MD, MPH Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi

Disclosure: Nothing to disclose.

Mark A Silverberg, MD, MMB, FACEP Assistant Professor, Associate Residency Director, Department of Emergency Medicine, State University of New York Downstate College of Medicine; Consulting Staff, Department of Emergency Medicine, Staten Island University Hospital, Kings County Hospital, University Hospital, State University of New York Downstate Medical Center

Mark A Silverberg, MD, MMB, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Richard H Sinert, DO Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Bassam Zeina, MD, PhD Consulting Staff, Department of Dermatology, Milton Keynes Hospital, UK

Bassam Zeina, MD, PhD is a member of the following medical societies: British Association of Dermatologists, British Medical Association, and Royal Society of Medicine

Disclosure: Nothing to disclose.

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Note the characteristic, ill-defined, hypopigmented macules in this 6-year-old child with pityriasis alba.
Lesions of pityriasis alba are usually bilateral and located on the face, arms, and neck.
The hypopigmentation produced by pityriasis alba may take a year or longer to return to normal.
This older patient with areas of hypopigmentation on the face has a common problem that would be included in the differential diagnosis of pityriasis alba. Several months earlier, he had areas of irritant contact dermatitis on his cheeks. When those resolved, he was left with areas of postinflammatory hypopigmentation. These should eventually repigment to an even skin tone.
Pityriasis alba.
 
 
 
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