Differential diagnoses: Skin pigmentation

Dr Nigel Stollery discusses the usual presenting features of four disorders

Naevus anaemicus

Presentation

  • Usually a single lesion is present
  • Can occur anywhere on the body
  • Localised pale areas not related to pigment
  • Over-reactive blood vessels reduce the colour of the skin
  • Pressure at the edge of the lesion will make it disappear as other vessels are compressed

Management

  • Treatment not required
  • Cosmetic camouflage can be very helpful

Vitiligo

Presentation

  • Very well-demarcated areas with total loss of pigment
  • Any areas can be affected
  • Can be associated with other autoimmune conditions
  • Affected areas have no scale and do not itch
  • May occur in scars (Koebner phenomenon)

Management

  • Treatment can be difficult
  • Potent topical steroids can help promote repigmentation
  • Cosmetic camouflage can help
  • In extensive disease, permanent depigmentation of remaining pigment can be undertaken with hydroquinone
  • Sun cream use is important

Lichen sclerosus

Presentation

  • Usually affects the genitals, but extragenital lesions can occur
  • Areas are usually symptomatic
  • Affected areas are white, shiny and atrophic
  • Cause unknown, women more affected than men
  • May be associated with autoimmune conditions

Management

  • Trunk lesions tend to be unresponsive to treatment
  • Genital lesions respond to topical steroids, which may reduce the risk of scarring
  • Spontaneous remission can sometimes occur
  • Affected areas may rarely undergo malignant change

Pityriasis alba

Presentation

  • Occurs on children’s faces
  • Relatively common, especially in darker-skinned children
  • Usually multiple poorly defined pale areas with fine scale
  • Condition is usually asymptomatic, with no itch
  • More noticeable during the summer months

Management

  • Reassurance can be given that this is self-limiting
  • No treatment is required
  • Usually clears in teenagers
  • Sun block can help

  • Dr Stollery is a GPSI in dermatology in Kibworth, Leicestershire

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