Вы находитесь на странице: 1из 6

PITYRIASIS ALBA

Dermatology and Venereology Department Medical Faculty of GadjahMada University Yogyakarta 2012

Introduction

Pityriasis alba, a non-specific dermatitis is a common condition mostly occurring in children between the ages of 3 and 16, but can be additionally seen in young adults. Both the sexes are equally susceptible. The condition is so named as pityriasis means scaly and alba is the word for white in Latin. Pityriasis alba has been regarded as a manifestation of atopic dermatitis though not always confined to atopics. Pityriasis alba is not associated with mortality. Pityriasis alba is usually a self-limited, asymptomatic disease. The condition typically lasts 1 year or more without treatment, and usually resolves after puberty or by the time the child reaches adulthood.

Pathophysiology
The patches in pityriasis alba are not totally depigmented as with vitiligo. The hypopigmentation with pityriasis alba is due to both reduced activity of melanocytes as well as fewer and smaller melanosomes; in vitiligo, on the other hand, there is total loss of both melanocytes and melanosomes. Histologically, the condition reveals subacute spongiotic dermatitis with decreased melanin within the epidermis. There is no specific known cause for this condition; however, studies to elucidate pathogenic factors seem to suggest that there are at least five separate causes for the condition. First, there is an increased incidence in individuals who bath excessively, defined as showering over once daily1. This could infer that removal of normal epidermal defensins and other natural protective substances from the skin surface, makes one more prone to this condition. Certainly, any inflammation of the skin may affect pigment cell function. Indeed, many consider the disease to be a mild form of eczema. Secondly, photosensitivity may also play a role in this entity1. The peak incidence of the condition coincides with the age when children begin to do more outdoor activities. Typical location of lesions is in sun-exposed areas. Also prolonged sun exposure of several hours also increases ones chances of developing the condition. Thus, the melanocytes appear to be sensitive to sun in these patients. Hypopigmentation can also be explained by damage to melanocytes and inhibition of tyrosinase by decarboxylic acid, azelic acid (a competitive inhibitor of tyrosinase), and/or tryptophan-derived metabolites produced by normal yeast, namely Malassezia furfur, a yeast that is part of the skin surfaces normal flora2,3. Thus, some pityriasis alba patients have a sensitivity to the byproducts of this fungus. Unlike tinea versicolor, the organism is not increased in numbers in pityriasis alba. Also, pathogenic fungus are not involved with this condition4.

Propionibacterium acnes bacteria, which live in the hair follicles, has been considered as a possible producer of a hypothetical depigmenting factor5,6. Pityriasis alba is frequently noted in children with early comedonal and popular acne. Propionibacterium acnes was yielded from cultured biopsy specimens taken from follicular lesional skin6. Propionibacterium acnes produces a number of bioactive virulence factors and is known for its inflammatory and immunomodulatory properties7,8. A number of exocellular enzymes and metabolites can directly damage host tissue including melanocytes9. Additionally, pityriasis alba may be merely secondary to postinflammatory changes. Indeed, studies of alterations of the stratum corneum by both hygroscopicity and waterholding capacity detectable by water sorption-desorption testing support this theory10.

Clinical presentation
Pityriasis alba usually appears as dry, fine scaled, pale patches, 0.5 to 6 cm in diameter; however, often the flakiness is not present. The rash is limited to the face in 50 % of cases, particularly the mid-forehead, malar ridges, and around the eyes and mouth; nevertheless, involvement of the shoulders, neck, back, and upper chest may predominate in others. Recurrent crops of new lesions may develop at intervals. It is symmetrical in distribution, but sometimes only marginally. The condition often begins as a pale pink or light brown macule with very indistinct margins, but it often just appears suddenly with decreased pigmentation. Macules vary from 5 to 30 mm or larger. Differential diagnosis11 Acquired (common) Vitiligo Postinflammatory hypopigmentation Tinea versicolor Congenital (uncommon) Albinism Piebaldism Tuberous sclerosis Hypomelanosis of Ito

Histopathologic features Microscopic features are most of the time non-specific. Vargas12 studied biopsy specimen of 39 patients. He suggested that a histopathological diagnosis of pityriasis alba may be proposed when the following features are seen in a biopsy specimen,

1) Irregular pigmentation by melanin of the basal layer. 2) Follicular plugging 3) Follicular spongiosis No significant difference in the number of melanocytes between lesional and normal skin was seen. These findings should be considered when diagnosing and differentiating PA from other hypopigmentary disorders.13

Treatment
Because the disease usually is self-limited and asymptomatic, medical therapy is often unnecessary. Pityriasis alba has no medical consequences, and the side effects of the medications may outweigh the cosmetic benefit of intervention. The most commonly used remedies (eg, emollients, topical steroids, psoralen plus ultraviolet light A photochemotherapy [PUVA]) appear to have limited efficacy. Emollients are used to reduce the scaling of the lesions, especially on the face. Topical steroids may help with erythema and pruritus during the initial lesions and may accelerate repigmentation of existing lesions. Use should be limited, with frequent breaks from use, to avoid long-term skin atrophy and steroid changes. Psoralen plus ultraviolet light A photochemotherapy (PUVA) may be used to help with repigmentation in extensive cases, although the recurrence rate is high after treatment is stopped. Use of topical corticosteroids for the treatment of pityriasis alba is limited by their potential side-effects, such as skin atrophy especially with long-term use on the face. Pimecrolimus cream 1% is a topical calcineurin inhibitor that has anti-inflammatory properties, lacks the cutaneous side-effects associated with steroids, and provide a potential benefit for the treatment of pityriasis alba. Pimecrolimus 1% has been proposed as an option over a 3-month period.14 Tacrolimus ointment 0.1% appears to be an effective and safe treatment for PA.15 Recently, treatment with a 308-nm excimer laser twice a week for 12 weeks has also been shown to be effective.16

Prognosis
Depigmentation is not permanent. Pityriasis alba generally is self-limited, and the lesions typically resolve by adulthood. The duration of symptoms is different for each patient. Parents should be aware lesions may persist for many months. Reports note

persistence up to one year4. Treatment may shorten the duration of the lesions to several weeks in certain cases.

References
[1] Weber MB, de Avila LGS, Albaneze R, de Oliveira OLM, Sudhaus BD, Cestari TF. Pityriasis alba: a study of pathogenic factors. JEADV 2002; 16: 463-8. [2] Thoma W, Kramer HJ, Maysert P. Pityriasis versicolor alba. JEADV 2005; 19: 14752. [3] Aljabre SHM, Alzayir AAAA, Abdulghani M, Osman OO. Pigmentary changes of tinea versicolor in dark-skinned patients. Int J Dermatol 2001; 40: 273-5. [4] Vinod S, Singh G, Dash K, Grover S. Clinico-epidemiological study of pityriasis alba. Ind J Dermatol 2002; 68: 338-40. [5] Relyveld GN, Menke HE, Westerhof W. Progressive macular hypomelanosis. Am J Clin Dermatol 2007; 8: 13-9. [6] Westerhof W, Relyveld GN, Kingswijk MM, de Man P, Menke HE. Propionibacterium acnes and the pathogenesis of progressive macular hypomelanosis. Arch Dermatol 2004; 140: 210-4. [7] Perry AL, Lambert PA. Propionibacterium acnes. Lett App Microbiol 2006; 42: 1858. [8] Burkhart CG, Cantrill J, Butcher CL, Lehmann PF. Propionibacterium acnes: interaction with complement and development of an enzyme-linked immunoassay for the detection of antibody. Int J Dermatol 1999; 38: 200-3. [9] Allaker RP, Greenman J, Osborne RH. The production of inflammatory compounds by Propionibacterium acnes and other skin organisms. Br J Dermatol 1987; 117: 17583. [10] Urano-Suehisa G, Tagami H. Functional and morphological analysis of the horny layer of pityriasis alba. Acta Dermato-Vener 1985; 65: 164-7. [11] Fitzpatrick TB. Fitzpatricks Dermatology in General Medicine. 4th ed. New York, NY: McGraw-Hill; 1993:966-968,1694,1984.

[12] Vargas-Ocampo-F. Pityriasis alba: a histologic study. Int J Dermatol 1993;32:870873. [13] In, S. I., Yi, S. W., Kang, H. Y., Lee, E. S., Sohn, S. and Kim, Y. C. (2009), Clinical and histopathological characteristics of pityriasis alba. Clinical and Experimental Dermatology, 34: 591597. doi: 10.1111/j.1365-2230.2008.03038 [14] Fujita WH, McCormick CL, Parneix-Spake A. An exploratory study to evaluate the efficacy of pimecrolimus cream 1% for the treatment of pityriasis alba. Int J Dermatol. Jul 2007;46(7):700-5. [15] Rigopoulos, D., Gregoriou, S., Charissi, C., Kontochristopoulos, G., Kalogeromitros, D. and Georgala, S. (2006), Tacrolimus ointment 01% in pityriasis alba: an open-label, randomized, placebo-controlled study. British Journal of Dermatology, 155: 152155. doi: 10.1111/j.1365-2133.2006.07181 [16] Al-Mutairi N, Hadad AA. Efficacy of 308-nm Xenon Chloride Excimer Laser in Pityriasis Alba. Dermatol Surg. Nov 28 2011

Вам также может понравиться