1.

Pityriasis alba
https://www.symptoma.com/en/info/pityriasis-alba
Pityriasis alba is a common disorder of the skin characterized by development of dry, pale
and fine patches on the face [1]. The patches are white colored and develop in round or oval
shape. The name of the disorder is derived from Latin words pityriasis meaning scaly and
alba meaning white.

This condition commonly strikes children and young adults. There is no specific treatment
and it gets corrected when the dryness is treated with moisturizer creams. The patches subside
over a period of time, but leave behind hypopigmented areas that eventually get back to the
original skin color [2].

Etiology

The exact cause that triggers the development of such a type of skin disorder is not yet
known. Pityriasis alba is not a result of any infection. Some theories suggest that pityriasis
alba is a mild form of either dermatitis or eczema [3]. Treatment of such skin diseases with
corticosteroids may leave behind hypopigmented scars which can develop into fine scale, dry,
white colored patches. In addition to these, the following are some more risk factors that are
known:

Excessive exposure to sun for longer duration and without any protection

Poor personal hygiene

Environmental factors such as temperature, altitude and humidity

Epidemiology

The exact prevalence of pityriasis alba is not known as the disease condition requires little
treatment and individuals seldom seek medical help. This skin disorder is common for
individuals below 16 years of age. Such a condition is more common in males compared to
females [4].

Pathophysiology

Pityriasis alba is a common accompaniment in children who are exposed to sun for long
hours without any protection. The hypopigmentation of the skin is caused due to decrease in
the number of active melanocytes as well as reduction in the number and size of
melanosomes. Such sequence of events is known to give rise to pityriasis alba.

Prognosis

The prognosis of the disease condition is generally favorable as the patches may resolve by
themselves. However, in some cases use of medicated creams may also be necessary. Patches
on the face can last for about a year. Some children may often experience recurrent bouts of
pityriasis alba until adulthood.

Complications

The most common and possible complication is the risk of sun burn in the hypopigmented
areas. However, with application of sun protective agents the risk does decrease significantly.
Apart from this, no other complications exist.

Presentation
Pityriasis alba is usually asymptomatic in nature. Individuals with such a type of skin
disorder can be present in any of the followings stages:

Papular erythematous lesions

Smooth hypochromic lesions

Papualar hypochromic lesions

The most common site for occurrence of the lesions is the cheek region followed by upper
arms, upper mid portion of the body and neck. The lesions that take an oval or round shape
are dry, flaky and scaly in nature. New lesions may develop in intervals and last for about a
year. There are also extensive variants of pityriasis alba that are less scaly and erythematous
which abound in the trunk area [5].

Workup
A thorough examination of the lesions on the face and rest of the body is usually enough to
diagnose the condition. However, in certain cases, potassium hydroxide test may be necessary
to rule out other skin disorders such as tinea versicolor, tinea corporis or tinea faciei [6]. In
severe cases, a biopsy of the affected skin may be required to be done for differential
diagnosis [7].

A type of test known as Woods light examination is done which would determine whether
the development of rash is due to vitiligo or some other cause. All these tests would be
necessary to rule out other associated skin diseases.

Treatment
Pityriasis alba is a benign condition that gets corrected by on its own. However, some
treatment is necessary to correct the cosmetic appearance of the individual. In addition,
parents of the affected children should always be educated about this skin disorder.

Patches are effectively treated with moisturizer creams and topical agents. Low potency
steroid creams are advised due to the associated side effects of such topical agents.
Immunomodulators are also found to be effective against pityriasis alba. 0.1% of tacrolimus
ointment and 1% of pimecrolimus creams are effective in reducing the patches associated
with this skin disorder [8].

The Psoralen with Ultraviolet Light A (PUVA) have been identified to help with the
repigmentation process of the skin in extensive cases of pityriasis alba, although recurrence
rate is high when the treatment is halted [9].

In addition to topical agents, laser therapy has also shown to be effective against pityriasis
alba. In this method, 308-nm laser is given to affected individuals twice a week for a period
of 12 weeks [10]. With laser treatment, the prognosis of the disease has been found to be
good.

Prevention
Pityriasis alba cannot be prevented as its exact etiology still remains a mystery. However,
affected individuals should take appropriate steps to prevent the onset of complications.

Application of sun protective creams and prescribed topical agents would help faster relief
from symptoms and would also provide protection against sun burn.

Patient Information
Definition

Pityriasis alba is a common skin disorder affecting children and the young population. Such a
type of skin disorder is characterized by development of patches on the face, upper neck and
upper portion of the body. The patches are scaly and white in color.

Cause

The exact factor that triggers the development of pityriasis alba is unknown. However,
research has suggested that such a type of skin disease is a form of eczema or dermatitis.
Pityriasis alba is not contagious in nature.

Symptoms

The lesions that develop are usually scaly and white colored patches that commonly appear
on the face. These patches do not get tan when exposed to sun; however can turn red. New
patches can appear in regular intervals and can last for more than a year.

Diagnosis

A physical examination of the patches is enough to diagnose the disease condition. However,
in some cases, Potassium hydroxide test may also be required to rule out other underlying
associated skin disorders. Certain cases may also demand skin biopsy to conduct differential
diagnosis of the disorder.

Treatment
Treatment requires application of topical agents and moisturizing creams. Low potency
corticosteroids topical agents are prescribed to avoid side effects due to these agents.
Individuals are also advised to apply sun protective lotions to prevent the affected area from
sun burn.

2. Pityriasis Alba
http://www.aocd.org/?page=PityriasisAlba

Pityriasis alba is a common skin condition first characterized by red, scaly patches. These
patches resolve leaving areas of scaling hypo-pigmentation, or lighter coloration. Patients do
not usually seek treatment of the lesions until this stage because of the concern for the
appearance of the scales. The cause of pityriasis alba is unknown, although it has been
regarded as a manifestation of another skin disorder called atopic dermatitis.

The lesions may be round, oval or irregular in shape and red, pink or skin colored. Several
patches may be observed at once usually on the face and arms. The duration of the rash is
variable, lasting from several months to over a year. Lesions can appear several times. The
lesions are obvious on those with darker skin. Patients with lighter skin will notice the rash
more frequently during the summer months as their skin tans. Young children are most often
affected but pityriasis alba tends to go away by adulthood. The loss of pigment associated
with pityriasis alba is not permanent.

Diagnosis is usually made solely on clinical signs and symptoms. A

biopsy may be performed but usually will show unimpressive changes
under the microscope.

Pityriasis alba sometimes works itself out spontaneously and does not
always require treatment. A moisturizer cream or lotion may be
recommended to retain moisture in the skin. A low potency topical
corticosteroid may also be prescribed to decrease inflammation and
reduce symptoms. Elidel, a nonsteroidal topical cream, can also reduce itching and redness
associated with pityriasis alba for those over the age of two.

3. Dermatology for the Allergist

https://waojournal.biomedcentral.com/articles/10.1097/WOX.0b013e3181e2eb2e

Dennis KimEmail author and

Richard Lockey

World Allergy Organization Journal20103:202

DOI: 10.1097/WOX.0b013e3181e2eb2e
 World Allergy Organization; licensee BioMed Central Ltd. 2010

Published: 15 June 2010

Abstract

Allergists/immunologists see patients with a variety of skin disorders. Some, such as atopic
and allergic contact dermatitis, are caused by abnormal immunologic reactions, whereas
others, such as seborrheic dermatitis or rosacea, lack an immunologic basis. This review
summarizes a select group of dermatologic problems commonly encountered by an
allergist/immunologist.

Keywords

dermatology dermatitis allergy allergic allergist skin disease

Introduction

Allergists/immunologists see patients with a variety of skin disorders. Some, such as atopic
and allergic contact dermatitis, are caused by abnormal immunologic reactions, whereas
others, such as seborrhoic dermatitis or rosacea, lack an immunologic basis. This review
summarizes a select group of dermatologic problems commonly encountered by an
allergist/immunologist.

Pityriasis Alba

Pityriasis alba is often considered to be a mild form of atopic dermatitis [10]. The disease affects 5%
of children aged 3 to 16 years with improvement after puberty. The lesions mostly affect the face,
neck, and upper extremities but can also occur on the trunk and lower extremities. The rash initially
appears as mildly erythematous and scaly circular plaques, 0.5 to 2 cm in diameter, followed by
hypopigmentation (Figure 2). The hypopigmentation may be more conspicuous in dark-skinned
individuals and typically lasts several months, but can remain for more than 1 year. The lesions are
usually asymptomatic, but patients may complain of local itching or burning.
 Figure 2 Pityriasis alba hypopigmentation. Reprinted with
permission from Habif, Clinical Dermatology, 5th ed. Elsevier, 2009.

Etiology is unknown, but a connection with atopy has been

suggested, thus making it important to inquire about personal or
family history of atopic diseases such as asthma, allergic
rhinitis, or eczema. The condition can be exacerbated by
excessive, unprotected sun exposure and environmental factors
such as temperature and humidity [11]. Differential diagnosis
includes other disorders that cause hypopigmentation such as
vitiligo, tinea versicolor, halo nevus, and nevus depigmentosus.
Although unnecessary for diagnosis, histology will show nonspecific acanthosis and mild
spongiosis with moderate hyperkeratosis and patchy parakeratosis [12].

Pityriasis alba responds very well to topical moisturizers and emollients. The lesions typically
resolve spontaneously without further treatment, but topical hydrocortisone (1% or 2.5%) or
tacrolimus can be used to relieve symptoms such as itching caused by inflammation.

4. PITYRIASIS ALBA
http://www.bad.org.uk/for-the-public/patient-information-leaflets/pityriasis-
alba/?showmore=1&returnlink=http%3A%2F%2Fwww.bad.org.uk%2Ffor-
the-public%2Fpatient-information-leaflets

What is pityriasis alba?

Pityriasis alba is a common skin complaint of children and young

adults. It appears as pink scaly patches which later leave pale
areas on the skin. These pale areas are more noticeable in people
with dark skin, and more pronounced after exposure to the sun
and the tanning of the non-affected skin. Pityriasis means skin scaling and alba means white.

What causes pityriasis alba?

The cause is unknown. It is thought to be due to a minor form of inflammation in the skin,
related to eczema, but it can occur in people who have no history of eczema at all. It is not
contagious.

Is pityriasis alba hereditary?

No.

What are the symptoms of pityriasis alba?

The rash can be mildly itchy but usually causes no problems. Sometimes it can be dry. It
often goes unnoticed when it first starts, but it is the loss of pigment that triggers people to
seek medical advice.

What does pityriasis alba look like?

It starts as rounded or oval pink rough patches of skin that fade to leave areas with reduced
pigment. The most commonly affected areas are the cheeks, chin and skin around the mouth.
It can also affect the trunk, arms and legs. The pale areas are often more noticeable after sun
exposure, particularly in people with darker skin, as these areas dont tan as usual.

How is pityriasis alba diagnosed?

This condition is usually diagnosed by its appearance and tests are not needed.

Can pityriasis alba be cured?

Pityriasis alba usually resolves spontaneously, and the skin colour gradually returns back to
normal with no scarring. However, it may persist for a few years, and may come and go
during this period, particularly in summer when the patches become prominent due to the
tanning of non-affected skin.

How can pityriasis alba be treated?

Medical treatment is not needed unless the skin is uncomfortable from itching. The dryness
can be helped by using a moisturiser and avoiding soap. If the patches are red or itchy, a mild
steroid cream (hydrocortisone) can be applied for a short period to improve symptoms.
Sunscreens in summer may prevent the patches becoming more noticeable by reducing the
tanning of the non-affected skin.

Self care (What can I do?)

Use moisturisers for the dryness

Do not use soap

Avoid sun especially in summer and in holiday by using high sunscreen products (no less than
30 SPF)

BRITISH ASSOCIATION OF DERMATOLOGISTS

PATIENT INFORMATION LEAFLET
PRODUCED DECEMBER 2015
REVIEW DATE DECEMBER 2018
 5. Pityriasis alba
https://www.nlm.nih.gov/medlineplus/ency/article/001463.htm

Pityriasis alba is a common skin disorder of patches of light-colored (hypopigmented) areas.

Causes

The cause is unknown but may be linked to eczema and a history of allergies. The disorder is
most common in children and teens. It is more noticeable in children with dark skin.

Symptoms

The problem areas on the skin (lesions) start as slightly red and scaly patches that are round
or oval. They usually appear on the face, upper arms, neck, and upper middle of the body.
After these lesions go away, the patches turn light-colored (hypopigmented).

The patches do not tan, but may get red quickly in the sun.

Exams and Tests

The health care provider can usually diagnose the condition by looking at the skin. Tests,
such as potassium hydroxide (KOH), may be done to rule out other skin problems. In very
rare cases, a skin biopsy is done.

Treatment

The provider may recommend the following treatments:

Moisturizer to help with the scales

Mild steroid creams

Medicine called immunomodulator applied to the skin to reduce inflammation

Laser treatment

The patches may clear up, but often return.

Outlook (Prognosis)

Pityriasis alba usually goes away on its own with patches returning to normal pigment over
time.

Possible Complications

Patches may get sunburned when exposed to sunlight. Applying sunscreen and using other
sun protection can help prevent sunburn.
When to Contact a Medical Professional

Call your health care provider if your child has patches of hypopigmented skin.

References

Habif TP. Light-related diseases and disorders of pigmentation. In: Habif TP, ed. Clinical
Dermatology: A Color Guide to Diagnosis and Therapy. 6th ed. Philadelphia, PA: Elsevier
Mosby; 2016:chap 19.

Patterson JW. Disorders of pigmentation. In: Patterson JW, ed. Weedon's Skin Pathology. 4th
ed. Philadelphia, PA: Elsevier Churchill Livingstone; 2015:chap 10.

Update Date 4/14/2015

Updated by: Kevin Berman, MD, PhD, Atlanta Center for Dermatologic Disease, Atlanta,
GA. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD,
MHA, Isla Ogilvie, PhD, and the A.D.A.M. Editorial team.

6. The Open Dermatology Journal, 2009, 3, 7-8 71874-3722/09 2009

Bentham Open
https://www.researchgate.net/publication/50434863_Pityriasis_Alba_Revisited_Perspectives_
on_an_Enigmatic_Disorder_of_Childhood

Pityriasis Alba: A Condition with Possibly Multiple

Etiologies
Craig G. Burkhart
*,1
and Craig N. Burkhart
2
1
University of Toledo College of Medicine, USA
2
University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
Abstract:
Pityriasis alba is a common hypomelanosis which is generally seen in young children. 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. This list includes dermatitis, photosensitivity, fungal and bacterial
pathogenesis, and
post-inflammatory alterations. An evaluation into causative factors translates into alternative
therapeutic options, which
may be advantageous with affected individuals.
When a disease has diverse clinical presentations and no
known cause, it is possible that one is looking at slightly
different diseases with similar clinical characteristics.
Pityriasis alba is a common condition in practice mostly
occurring in children between the ages of 3 and 16, but can
be additionally seen in young adults. It usually appears as
dry, fine scaled, pale patches, 0.5 to 6 cm in diameter; how-
ever, often the flakiness is not present. The rash is limited to
the face in 50 % of cases, particularly the mid-forehead, ma-
lar ridges, and around the eyes and mouth; nevertheless, in-
volvement of the shoulders, neck, back, and upper chest may
predominate in others. 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 pigmenta-
tion. Macules vary from 5 to 30 mm or larger.
The condition is so named as pityriasis means scaly and
alba is the word for white in Latin. Of note, 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. A differential diag-
nosis would include vitiligo, psoriatic leukoderma, tinea ver-
sicolor, follicular mucinosis, pityriasis lichenoides chronica,
sarcoidosis, adult T-cell leukemia/lymphoma, and mycosis
fungoides.
There is no specific known cause for this condition; how-
ever, 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 daily [1]. This
could infer that removal of normal epidermal defensins and
other natural protective substances from the skin surface,
*Address correspondence to this author at the University of Toledo School
of Medicine, 5600 Monroe Street, Suite 106B, Sylvania, OH 43560, USA;
Tel: 419-885-3403; Fax: 419-885-3401; E-ma
il: cgbakb@aol.com
makes one more prone to this condition. Certainly, any in-
flammation of the skin may affect pigment cell function.
Indeed, many consider the disease to be a mild form of ec-
zema.
Secondly, photosensitivity may also play a role in this
entity [1]. The peak incidence of the condition coincides
with the age when children begin to do more outdoor activi-
ties. 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 flora [2, 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 condition [4].
Propionibacterium acnes
bacteria, which live in the hair
follicles, has been considered as a possible producer of a
hypothetical depigmenting factor [5, 6]. Pityriasis alba is
frequently noted in children with early comedonal and popu-
lar acne.
Propionibacterium acnes
was yielded from cultured
biopsy specimens taken from follicular lesional skin [6].
Propionibacterium acnes
produces a number of bioactive
virulence factors and is known for its inflammatory and im-
munomodulatory properties [7, 8]. A number of exocellular
enzymes and metabolites can directly damage host tissue
including melanocytes [9].
Additionally, pityriasis alba may be merely sec
ondary to
postinflammatory changes. Indeed, studies of alterations of
the stratum corneum by both hygroscopicity and water-
holding capacity detectable by water sorption-desorption
testing support this theory [10].
An evaluation into causative factors translates into alter-
native therapeutic options, which is advantageous with con-
ditions which lack a definitive cure. Evaluations of causes of
pityriasis alba are therefore warranted.

7. AN UPDATED REVIEW ON PITYRIASIS ALBA

www.wjpr.net Vol 3, Issue 6, 2014.
2162
Ramam et al. World Journal of Pharmaceutical Research
AN UPDATED REVIEW ON PITYRIASIS ALBA
Sripada Ramam*, Bondada Neelima, Bonam Jyothi, Bondada Bharatha Pushya Raja
Sanjay, Magharla Dasaratha Dhana Raju, Gudimetla Lilli Sailaja.
Department of Pharmacy practice, GIET School of Pharmacy, Rajahmundry, Andhra
Pradesh, India 533296.
ABSTRACT
Pityriasis Alba (P. Alba) is a relatively common skin disorder
characterized by the presence of fine scaly hypo pigmented macules or
patches. It was first described by fox in 1923. He was unable to
account for its pathogenesis and kept unnamed for many years. There
was no gender variability for this skin disorder and was prevalent all
over the world. The exact etiology of P. Alba is not known. Lesions are
usually oval or round or irregular in shape with red or pink or skin
coloured and may ranges from 4-20 in number. They are often
characterized by hypo pigmented patches with 0.5-6cms in diameter.
Spongiosis, acanthosis, hyperkeratosis, parakeratosis are the
histological findings that can be observed during diagnosis. Low
potency topical steroids like Hydrocortisone (0.5%) and (1%), Desonide (0.05%), Tacrolimus
(0.1%), Pimecrolimus (1%), Calcitriol (0.0003%), Sorbityl furfural palmitate cream, Elidel,
Lac-Hydrin, Zetar (2%) in Cordran cream, Vioform cream (1%) were found to be effective in
treating this disorder. Treatment with 308nm excimer laser twice a week for 12 weeks is also
an effective treatment approach. Patients should be strictly advised not to expose to harsh
sunlight. Lesions become prominent in sun exposure so in order to reduce the discrepancy,
sunscreen creams or lotions are recommended. In some circumstances, P. Alba remained
mysterious to understand because of no exact etiology, histological pattern and effective
treatment approaches. Hence there is an urgent need for the evaluation of etiology,
pathogenesis, diagnosis and effective therapeutic plans to provide better patient care for
individuals with P. Alba.
Key words: Pityriasis Alba, Erythema streptogenes, Impetigo furfuracea, Pityriasis
streptogenes, Pityriasis simplex, Spongiosis.
World Journal of Pharmaceutical ReseaRch
SJIF Impact Factor 5.045
Volume 3, Issue 6, 2162-2171. Review Article ISSN 2277 7105
Article Received on
30 June 2014,
Revised on 25 July 2014,
Accepted on 20 August 2014
*Correspondence for
Author
Sripada Ramam
Department of Pharmacy
practice, GIET School of
Pharmacy, Rajahmundry,
Andhra Pradesh, India 533296..
www.wjpr.net Vol 3, Issue 6, 2014.
2163
Ramam et al. World Journal of Pharmaceutical Research
INTRODUCTION
Pityriasis Alba (P. Alba) is a relatively common skin disorder characterized by the presence
of fine scaly hypo pigmented macules or patches [1]. The term P. Alba is derived from two
Latin words pityriasis (scaly) and alba (white patches) [2]. These white patches are most
commonly seen in the areas like face, trunk, neck [3] and around the mouth [4]. It was first
described by fox in 1923. He was unable to account for its pathogenesis and kept unnamed
for many years [5]. This skin disorder is also called as erythema streptogenes, pityriasis
streptogenes, impetigo furfuracea and pityriasis simplex [6].
There are two types of P. Alba that includes endemic P. Alba and atopic dermatitis related P.
Alba with post inflammatory hypo pigmentation. Endemic P. Alba usually occurs in infants
and children of low socioeconomic condition [7]. P. Alba is best characterized as a form of
dermatitis which occurs due to reduction in melanocytes and melanosomes with no defect in
melanosomal transfer to keratinocytes [8]. It results primarily from inflammation involving the
epidermis and superficial dermis, which interferes the normal pigmentation. Loss of pigment
is not permanent in this skin disorder [9].
Epidemiology
According to some investigations, females are more prone to this skin disorder than males
and in some investigations male predominance has been reported slightly [10]. Hence, we can
describe that there was no gender variability for this skin disorder [11]. This disorder was
prevalent all over the world and the prevalence may vary from country to country [12]. Table 1
represents the prevalence rates of P. Alba in different parts of the world.
P. Alba occurs in all age groups, and was more predominant in children between the ages of
3-16 years. This skin disorder was affecting 5% of pediatric population among the worldwide
distribution [10, 13]. The prevalence of P. Alba among preadolescent children may ranges from
1.9-5.25% [14]. A retrospective analysis revealed that around 90% of patients who were
diagnosed with P. Alba were between the ages of 6-12years and the remaining 10% patients
were between the ages of 13-16years [15]. A ten year survey on P. Alba showed a prevalence
rate of 81% and the patients were at the age of 15 [16]. A study was conducted among 9955
school going children who were between the ages of 6-16 years in topical region have
reported a prevalence rate of 9.9% [17, 18]. According to a study, the higher incidence of P.
Alba in school children is due to poor socioeconomic background [19]. P. Alba spots are
common in all skin colours but are more often noticeable in darker skin [20]. According to the
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2164
Ramam et al. World Journal of Pharmaceutical Research
existing literature, pigmentary changes among blacks and whites were found to be 9% and
1.7% respectively [10].
Table 1: Prevalence rates of Pityriasis Alba in different parts of the world [17, 19-24]
Name of the country Prevalence rates
Brazil 9.9%
Egypt 13.49%
Hong Kong 1%
India 8.4-31%
Iraq 38.2%
Nepal 5.2%
Romania 5.1%
Turkey 12%
United States 5% (approximately)
Etiology
The exact etiology of P. Alba is not known. Some microorganisms such as pityrosporum,
streptococcus, staphylococcus, and aspergillus are known to be the causing factors but are not
yet confirmed [25]. Triggering factors that may cause P. Alba includes (i) deficiency of
vitamins & calcium (ii) temperature variations, humidity and excessive sunlight exposure (iii)
frequent bathing (iv) usage of various harsh detergents & soaps (v) dry and itching skin (vi)
hypo pigmentation (vii) worms & parasites (viii) stress (ix) deficiency of copper and (x)
atopic diseases and/or a family history of eczema [3, 10, 13, 26, 27].
Symptoms
Lesions are usually oval or round or irregular in shape with red or pink or skin coloured and
may ranges from 4-20 in number [3]. They are often characterized by hypo pigmented patches
with 0.5-6cms in diameter. Patch distribution is symmetrical and sometimes marginal.
Sometimes it may be associated with mild itching [4]. P. Alba is not symptomatic, many
patients do not mention lesions and are often found incidentally [16]. Lesions are more
commonly limited to the face especially, in areas like mid forehead, malar ridges, around the
eyes and mouth. The other areas that may be affected by this skin disorder are shoulders,
neck, back and upper chest [10]. Mostly lesions are found on the upper extremities and
occasionally on the lower extremities [14]. Mostly P. Alba may become worse during summer,
because of skin tans. During winter the patients may experience dry scaly appearance [17, 18].
www.wjpr.net Vol 3, Issue 6, 2014.
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Ramam et al. World Journal of Pharmaceutical Research
Figure 1: White patches of p alba on cheeks and around the mouth
Diagnosis
P. Alba can be diagnosed by using clinical findings. Spongiosis is a consistent histological
finding in the diagnosis of P. Alba. Other histological findings such as acanthosis,
hyperkeratosis, parakeratosis can often be seen [28]. P. Alba usually seen with 2 or 3 macules
or patches at a time in several stages. According to Vargas-Ocampo et al., there are 3 stages
of P. Alba. The early stage is known as papular erythematous stage, the intermediate stage is
known as papular hypo chromic stage which is also called as follicular pityriasis alba and the
final stage is described as smooth hypo chromic stage. The first (early) stage begins as
erythematous with an elevated border that may lasts for weeks. In the second stage
(intermediate), the patch may be replaced by a smooth scaly layer. These two stages are
marked by the presence of pinpoint follicular papules. In third stage, these appear as a visible,
round and hypo pigmented macule with well defined borders. The patient usually seeks
medical treatment during this stage [29].
Differential diagnosis includes vitiligo, classic P. Alba, extensive P. Alba, progressive
macular hypomelanosis, pigmenting P. Alba, post inflammatory hypo pigmentation, tuberous
sclerosis, nevus depigmentosus, nevus anemicus, psoriatic leukoderma, tinea verscicolor,
follicular mucinosis, pytiriasis lichenoides chronica, sarcoidosis, nummular eczema, adult
tcell
leukemia/ lymphoma, and mycosis fungoides [13]. Sometimes P. Alba may get confused
with vitiligo. Both P. Alba and vitiligo are hypo pigmented inflammatory skin diseases. In P.
Alba the loss of pigmentation starts at the centre and extends peripherally, where as in vitiligo
the loss of pigmentation is usually complete. A recent study revealed that P.Alba might
convert into vitiligo and the four findings that might justify the above statement in their study
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are (i) genetic susceptability as confirmed by strong family history of vitiligo among
individuals with P. Alba (ii) close association between vitiligo and P. Alba in the same
patients (iii) a huge percentage of P. Alba progressed to vitiligo and (iv) the high association
of P. Alba and Koebners phenomena [20].
Skin Biopsy is not usually necessary or recommended in diagnosing P. Alba but may be
indicated in the diagnosis of mycosis fungoides. Sometimes pityriasis alba is often confused
with tinea versicolor. The diagnosis can be carried out by a Potassium Hydroxide (KOH)
examination. The surface of the skin was scrapped off in a small amount onto a glass slide.
Then add potassium hydroxide and observe under the microscope. Fungal elements can be
observed in conditions like tinea verscicolor but not with P. Alba. KOH stain shows a
positive result not only in case of tinea verscicolor but also in the cases of tinea fociei and
tinea corposis [30].
Treatment
Corticosteroids and Immuno suppressors
Low potency topical steroids like Hydrocortisone (0.5%) and (1%), Desonide (0.05%) are
required for treating the symptoms like erythema, pruritis associated with initial lesions and
repigmentation of existing lesions [31-33]. These are extremely safe for prescribing in young
children but prolonged use on face is not recommended. Recently immunosupressors like
Tacrolimus (0.1%) and Pimecrolimus (1%) had shown an excellent response in atopic related
P. Alba. In some countries, prescribing of Tacrolimus (0.1%) for pediatrics was not approved
[34, 35]. Instead of Tacrolimus (0.1%), we can prescribe Tacrolimus (0.03%) which was
indicated as an off-labeled drug [29]. For endemic P. Alba no clinical trials were reported. In
an open label, placebo controlled study, Tacrolimus ointment had shown efficacy and safety
in 60 pediatric patients with P. Alba. According to some small open label studies,
Pimecrolimus cream was found to be effective in treating p.alba among African and
American adult patients [36].
Calcitriol and Other Drugs
Calcitriol (0.0003%) is an endogenous hormonally active derivative of vitamin D. It activates
melanocytes, promotes melanin synthesis and has immuno-modulation properties. These
features are useful in treating endemic P. Alba [37-41]. For chronic lesions on the trunk, tar
paste can be used. But, Tar containing topicals are unfavorable in terms of patient adherence
and efficacy too. Bland Emollient creams should be prescribed to reduce scaling of lesions on
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face [42]. According to a double blind placebo-controlled trail, Sorbityl furfural palmitate
cream was found to be effective in treating mild to moderate atopic dermatitis in P. Alba
patients. In another study, patients who were between the ages of 2 months to 15 years, a
significant improvement was observed with this cream when compared to those with on
placebo after 15 and 30 days [1]. Elidel, a non steroid topical cream, can also be prescribed to
reduce itching and erythema associated with P. Alba for those over the age of 2 years. Lac-
Hydrin, Zetar (2%) in Cordran cream and Vioform cream (1%) were also found to be
effective in treating this disorder [35, 36].
Other treatment approaches
Usually, the patches of P. Alba do not darken in sunlight. In order to decrease the discrepancy
in colouration against the surrounding normal skin, effective sun protection is essential.
Cosmetic camouflage can be considered as a choice for this [33,34]. In severe cases, Psoralen
ultra violet light A (PUVA) therapy was considered but the recurrence rate will be more after
discontinuation of the treatment. Treatment with 308nm excimer laser twice a week for 12
weeks is also an effective treatment approach for treating this skin disorder [42].
Patient Education
The precautions to be taken by the P. Alba patients are: Patients should be strictly advised not
to expose to harsh sunlight. Lesions become prominent in sun exposure so in order to reduce
the discrepancy, sunscreen creams or lotions are recommended. Sunscreens use can be
recommended to all patients with various skin types. Several sunscreens have emollient
information (eg: water based vs oil based) listed on the label, if not listed it is better to check
with the pharmacist/ physician. Prefer moisturizing soaps for bathing and apply moisturizers
like petroleum jelly or fragrance free ointments and creams to get the skin to be moisturized.
Presence of chlorine in pool water may cause tanning. Hence, swimming should be avoided.
Bacterial infections, fungal infections, parasitic infections, nutritional deficiencies and
anemia are more frequent in case of patients with P. Alba. Hence, prominent care towards the
health is a significant aspect. Advice the patients to attend for the periodic skin examination
without fail. Provide awareness regarding health education on personal hygiene and clean
environment [15, 43, 44].
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CONCLUSION
The presence of hypo pigmented lesions remains difficult to find, remaining the term P. Alba
more pertinent and precise. In some circumstances, P. Alba remained mysterious to
understand because of no exact etiology, histological pattern and effective treatment
approaches. Hence there is an urgent need for the evaluation of etiology, pathogenesis,
diagnosis and effective therapeutic plans to provide better patient care for individuals with P.
Alba.
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