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Blotches: Light rashes

Basic Dermatology Curriculum

Last updated Sept 2015

Module Instructions

The following module contains a number of blue, underlined terms which are hyperlinked to the dermatology glossary, an illustrated interactive guide to clinical dermatology and dermatopathology.

We encourage the learner to read all the hyperlinked information.

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Goals and Objectives The purpose of this module is to help medical students

develop a clinical approach to the evaluation and initial management of patients presenting with light rashes.

After completing this module, the learner will be able to: • Identify and describe the morphology of common light

rashes • Describe the use of Wood’s lamp and KOH exam to

evaluate light spots • Recommend an initial treatment plan for selected light

rashes • Determine when to refer to a patient with a light rash to a

dermatologist

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Case One Heather Doyle

Case One: History HPI: Heather Doyle is a 10-year-old girl who presents with

several lightly colored spots on her knees and hands over the past 8 months. They do not itch. Her mother reports they have not improved with over-the-counter hydrocortisone cream.

PMH: no chronic illnesses or prior hospitalizations Allergies: penicillin (rash) Medications: none Family history: grandmother with diabetes Social history: lives at home with parents; attends

elementary school; takes karate lessons ROS: negative

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Case One: Skin Exam

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Case One, Question 1

Heather has some light colored, non-scaly, flat spots on her knees. Which of the following will likely aid in the diagnosis?

a. Dermatoscope b. Potassium hydroxide (KOH) exam c. Swab for bacterial culture d. Wood’s light e. Gram stain

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Case One, Question 1

Answer: d Heather has some light colored, non-scaly, flat spots on her knees. Which of the following will likely aid in the diagnosis?

a. Dermatoscope b. Potassium hydroxide (KOH) exam c. Swab for bacterial culture d. Wood’s light e. Gram stain

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Case One: Wood’s light exam

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Case One, Question 2 How would you describe Heather’s exam?

a. Well-circumscribed hypopigmented macules and patches

b. Well-circumscribed depigmented macules and patches

c. Poorly circumscribed hypopigmented macules and patches

d. Poorly circumscribed depigmented papules and plaques

e. Poorly circumscribed hyperpigmented macules and patches

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Case One, Question 2 Answer: b How would you describe Heather’s exam? a. Well-circumscribed hypopigmented macules and

patches b. Well-circumscribed depigmented macules and

patches c. Poorly circumscribed hypopigmented macules and

patches d. Poorly circumscribed depigmented papules and

plaques e. Poorly circumscribed hyperpigmented macules and patches

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Vitiligo Lesions of vitiligo are well-

circumscribed depigmented macules and patches.

The Wood’s light exam distinguishes hypopigmented and depigmented lesions.

Very few rashes other than vitiligo are completely depigmented.

More Examples of Vitiligo

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Demonstration of bright white (depigmented) area with Wood’s light illumination

Vitiligo: The Basics • Vitiligo is caused by an autoimmune attack

on melanocytes, the cells that produce skin pigment

• It favors areas of trauma (knees, elbows, fingers, mouth, eyes, genitalia) – Can have associated white hair

• There is an association with other autoimmune disorders – Heather’s vitiligo may be autoimmune, given her

family history of diabetes mellitus

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Vitiligo: The Basics

Treatment options include • Potent topical steroids or tacrolimus

ointment • Phototherapy (Narrow band UVB,

UVA) • Cosmetic cover-ups

Refer vitiligo patients to dermatology for initial evaluation

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Is this hypopigmented or depigmented? Use the Wood’s light.

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Wood’s light exam

Lighter areas without complete loss of pigment are “hypopigmented”

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Steroid hypopigmentation Skin lightening can result from potent topical or

intralesional corticosteroids The risk is higher in darker skin types. Counsel

patients and parents on this risk. Avoid this side effect by using appropriate

strength topical steroids • Use high-potency steroids for short durations • Then back off to mid-potency or low-potency steroids

for maintenance

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Case Two Tony Maddox

Case Two: History HPI: Tony Maddox is a 32-year-old man who presents

with “blotches” on his upper back and chest for several years. They are more noticeable in the summertime.

PMH: back pain, hyperlipidemia, birthmark (Nevus of Ito) on his left chest

Allergies: none Medications: NSAID as needed Family history: none Social history: aircraft mechanic ROS: negative

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Case Two: Skin Exam

Case Two, Question 1

Mr. Maddox’s skin exam shows hypopigmented, slightly scaly macules on his upper chest. Which is the best test to confirm the diagnosis?

a. Bacterial culture b. Direct fluorescent antibody (DFA) test c. Potassium hydroxide (KOH) exam d. Wood’s light e. Gram stain

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Case Two, Question 1

Answer: c Mr. Maddox’s chest shows hypopigmented, slightly scaly macules on his upper chest. Which is the best test to confirm the diagnosis?

a. Bacterial culture b. Direct fluorescent antibody (DFA) test c. Potassium hydroxide (KOH) exam d. Wood’s light e. Gram stain

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Case Two: KOH exam

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The KOH exam shows short hyphae and small round spores. This “spaghetti and meatball” finding is diagnostic of tinea (pityriasis) versicolor.

Spores (yeast forms)

Short Hyphae

Diagnosis: Tinea versicolor

Based on his skin findings and KOH exam, Mr. Maddox has tinea versicolor

It’s called “versicolor” because it can be light, dark, or pink to tan

Let’s look at some examples of the various colors of tinea versicolor

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Tinea versicolor: lighter

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Tinea versicolor: darker

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Tinea versicolor: pink or tan

Case Two, Question 2

What is the best treatment for Mr. Maddox? a. Ketoconazole shampoo b. Narrow band UVB phototherapy c. Oral griseofulvin d. Tacrolimus cream e. Triamcinolone cream

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Case Two, Question 2

Answer: a What is the best treatment for Mr. Maddox?

a. Ketoconazole shampoo b. Narrow band UVB phototherapy (may worsen

appearance by increasing contrast) c. Oral griseofulvin (does not work for

Malassezia species) d. Tacrolimus cream (does not fight yeast) e. Triamcinolone cream (does not fight yeast)

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Case Two, Question 3

What is true about the treatment of tinea versicolor?

a. Normal pigmentation should return within a week of treatment

b. Oral azoles should be used in most cases c. Topical steroids are an excellent choice d. Antibiotic ointments are an excellent choice e. When using shampoos as a body wash

treatment, leave on for ten minutes before rinsing

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Case Two, Question 3

Answer: e What is true about the treatment of tinea versicolor?

a. Normal pigmentation should return within a week of treatment (usually takes weeks to months to return to normal)

b. Oral azoles should be used in most cases (can be used for more extensive involvement)

c. Topical steroids are an excellent choice (does not fight yeast) d. Antibiotic ointments are an excellent choice (does not fight

yeast) e. When using shampoos as a body wash treatment, leave on

for 10 minutes before rinsing

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Case Three Shaun Lee

Case Three: History HPI: Shaun Lee is a 20-year-old male seen in the hospital

with a worsening light colored scaling rash on his face. It has been getting worse since he stopped taking HAART for HIV. He also has painful erosions and ulcers in his mouth for 2 months and was admitted for pneumonia.

PMH: HIV, extensive molluscum contagiosum, pneumonia Allergies: penicillin (rash) Medications: levofloxacin Family history: noncontributory Social history: lives at home with parents; father does not

believe he should take HIV medications ROS: fatigue, dyspnea, fevers

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Case Three: Skin Exam

Case Three, Question 1

Shaun’s exam shows hypopigmented scaling patches on his central face, eyebrows, and hairline. KOH is negative. What is the most likely diagnosis?

a. Pityriasis alba b. Seborrheic dermatitis c. Steroid hypopigmentation d. Tinea versicolor e. Tinea faceii

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Case Three, Question 1

Answer: b Shaun’s exam shows hypopigmented scaling patches on his central face, eyebrows, and hairline. KOH is negative. What is the most likely diagnosis?

a. Pityriasis alba (no history of atopy) b. Seborrheic dermatitis c. Steroid hypopigmentation (not using steroids) d. Tinea versicolor (KOH negative) e. Tinea faceii (KOH negative)

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Seborrheic dermatitis

Seborrheic dermatitis is a very common inflammatory reaction to the Malassezia (formerly Pityrosporum) yeast that thrives on seborrheic (oil-producing) skin Seborrheic dermatitis is often worse in HIV-

positive patients, immunosuppressed patients (organ transplant, cancers) and patients with neurologic/psychiatric disorders such as Parkinson’s disease

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Seborrheic dermatitis

• It presents as erythematous macules/patches with waxy scale

• Seen on scalp, hairline, eyebrows, eyelids, central face, nasolabial folds, external auditory canals, or central chest

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Seborrheic dermatitis

Favors central chest. May be hypopigmented or erythematous.

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Seborrheic dermatitis

Often hypopigmented in darker skin types

Case Three, Question 2

What is the best treatment for Shaun? a. Caspofungin IV infusion b. Clobetasol proprionate cream (high

potency steroid) c. Desonide cream (low potency steroid) d. Imiquimod cream e. Narrow band UVB phototherapy

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Case Three, Question 2

Answer: c What is the best treatment for Shaun?

a. Caspofungin IV infusion (this is a systemic antifungal for severe infections)

b. Clobetasol proprionate cream (would work, but too potent for use on the face)

c. Desonide cream (low potency steroid) d. Imiquimod cream (irritating; for warts, actinic

keratoses) e. Narrow band UVB phototherapy (doesn’t work)

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Seborrheic dermatitis treatment Antidandruff shampoo

• Ketoconazole (Nizoral), selenium sulfide, zinc pyrithione (Head & Shoulders) shampoos

• Lather, leave on 10 minutes, rinse • 3-5 times weekly until under control

• Rotating shampoos associated with increased benefit

Low-potency topical steroid (e.g. desonide) for flares

• Use BID for flares Can also use topical ketoconazole or ciclopirox, or

topical pimecrolimus

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Seborrheic dermatitis (scalp)

• Severe scalp seborrheic dermatitis may need topical steroids; adjust to severity, patient ethnicity

• Examples – Clobetasol solution – Clobetasol foam – Fluocinolone in peanut oil (DermaSmooth™)

• Refer to Dermatology for assistance: consideration of use of compounding pharmacies for desired strength of topical steroid and vehicle

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Case Four Damien Gonsalves

Case Four: History HPI: Damien Gonzales is a 10-year-old boy who

presents with light spots on his face. PMH: had “eczema” as infant and young child Allergies: none Medications: none Family history: brother with asthma, mother has

seasonal allergic rhinitis Social history: lives at home with parents; student

in fifth grade ROS: negative

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Case Four: Skin Exam

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Case Four: Question

Damien has hypopigmented patches on his cheeks bilaterally. The most likely diagnosis is:

a. Pityriasis alba b. Seborrheic dermatitis c. Tinea versicolor d. Vitiligo e. Impetigo

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Case Four: Question Answer: a Damien has hypopigmented patches on his cheeks bilaterally. The most likely diagnosis is:

a. Pityriasis alba (atopic history supports this) b. Seborrheic dermatitis (usually more central) c. Tinea versicolor (rarely occurs on the face) d. Vitiligo (would be depigmented, not

hypopigmented) e. Impetigo (not honey crusted)

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Pityriasis alba Pityriasis alba is a mild form of atopic dermatitis

of the face in children As in all atopic dermatitis, the first goal is

moisturization Use of sunscreens minimizes tanning, thereby

lessening the contrast between involved and normal skin

If moisturization and sunscreen do not improve the hypopigmentation, consider low strength topical steroid short term

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A note on postinflammatory hypopigmentation

Some patients heal with light spots from any rash/dermatitis

Stigma may be caused by fear of infectious diseases

Social impact can be more severe than original rash

Pigmentation may return slowly It is important to treat rashes

aggressively to avoid this if possible

Not from treatment but from inflammation

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Common light rashes

Vitiligo Tinea versicolor Seborrheic dermatitis Pityriasis alba

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Comparing common light rashes

Face Trunk Arms, Legs Notes

Seborrheic dermatitis X X Central face

Greasy scale

Tinea versicolor X +

KOH positive “inducible” scale

Vitiligo X + X Depigmented (“bone

white”) on Woods light exam

Pityriasis alba X + History of atopy

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Take Home Points: Light Rashes Vitiligo is totally depigmented (“bone white”) on Wood’s light

examination and often occurs in areas of trauma Hypopigmented macules on the upper back and chest should be

scraped for KOH exam to rule out tinea versicolor Hypopigmented patches on the central face with greasy scale

are usually seborrheic dermatitis Hypopigmented patches on the face (also upper arms and legs)

of atopic children are usually pityriasis alba; reassure parents and encourage use of sunscreen and moisturizers

Potent corticosteroids, topical or injected, can cause hypopigmentation; warn patients of this possible side effect when prescribing or injecting

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Acknowledgements This module was developed by the American

Academy of Dermatology Medical Student Core Curriculum Workgroup from 2008-2012.

Primary author: Patrick McCleskey, MD, FAAD. Peer reviewers: Timothy G. Berger, MD, FAAD;

Peter A. Lio, MD, FAAD; Jennifer Swearingen, MD; Sarah D. Cipriano, MD, MPH.

Revisions, April 2011: Patrick McCleskey, MD, FAAD

Last revised September 2015: Nora Shumway, MD; Susan K. Ailor, MD, FAAD

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End of the Module Berger T, Hong J, Saeed S, Colaco S, Tsang M, Kasper R. The Web-Based

Illustrated Clinical Dermatology Glossary. MedEdPORTAL; 2007. Available from: www.mededportal.org/publication/462.

Habif TP. Clinical Dermatology: a color guide to diagnosis and therapy, 6th ed. St. Louis, MO:Elsevier; 2016.

Lio PA. Little white spots: an approach to hypopigmented macules. Arch Dis Child Pract Ed 2008;93:98-102.

Marks Jr JG, Miller JJ. Chapter 13. White Spots (chapter). Lookingbill and Marks’ Principles of Dermatology, 5th ed. Elsevier; 2013:172-182.

Wolverton SE. Systemic antifungal agents (Chapter 9) and Therapeutic Shampoos (Chapter 47). Comprehensive Dermatologic Drug Therapy, 3rd ed. Elsevier; 2013:98-120, 562-569.

Clark G, Pope S, Jaboori K. Diagnosis and treatment of seborrheic dermatitis. Am Fam Physician. 2015;91(3):185-190.

Ezzedine K, Elefheriadou V, Hons MW, van Geel N. Vitiligo. Lancet. 2015:386:74-84.

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To take the quiz, click on the following link: https://www.aad.org/quiz/blotches-light-rashes-learners