|
 
 |
| ORIGINAL ARTICLE |
|
| Year : 2022 | Volume
: 9
| Issue : 3 | Page : 182-187 |
|
Pityriasis alba: current clinicoepidemiologic scenario in a rural tertiary care hospital in central India
Komal A Ramteke1, Sumit Kar1, Safa Patrick1, Ajinkya Sawant1, Vivek Ambhore2
1 Department of Dermatology, Venereology and Leprosy, MGIMS, Sevagram, Wardha, Maharashtra, India
2 Department of General Medicine, IGGMC, Nagpur, Maharashtra, India
| Date of Submission | 22-Dec-2020 |
| Date of Decision | 20-May-2021 |
| Date of Acceptance | 03-Oct-2021 |
| Date of Web Publication | 30-Nov-2022 |
Correspondence Address:
Dr. Sumit Kar
Department of Dermatology, Venereology, and Leprosy, MGIMS, Sevagram, Wardha 442102, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/pigmentinternational.pigmentinternational_
Background: Pityriasis alba (PA) is a common, benign skin disorder occurring predominantly in children and adolescents. It is characterized by the presence of multiple, ill-defined, hypopigmented patches with fine scaling particularly over the face. Aims and objectives: To study the clinical characteristics and epidemiologic parameters in the context of current scenario in a rural tertiary care hospital in central India. Materials and methods: We conducted a descriptive observational study over a period of 1 year. We studied 100 clinically diagnosed patients with PA of the age group 2 to 15 years during this study. Results: Most common age group of patients observed was 6 to 10 years. About 87% patients had Fitzpatrick skin type IV followed by type III (7%) and type V (6%). Male to female ratio was 1.17:1. Maximum patients belonged to class III (50%) followed by class IV (37%) and class V (10%) according to the modified Kuppuswamy socioeconomic status scale (2018). Maximum patients had age of onset ranging from 6 to 10 years. Clinical characteristics revealed that maximum patients had 0 to 5 patches, with a duration of 1 to 2 months most commonly over cheeks. Associated features such as itching, scaling, and erythema were present in 18%, 98%, and 1% of the patients, respectively. Pallor was observed in 28% patients. However, significant history of atopy was elucidated in only 21% of patients. Around 6% patients showed positive family history of having PA and 14% having a positive history of atopy in first-degree family members. Conclusion: Due to the easily visible hypopigmented patches most commonly over face, PA is a common cause of concern in pediatric age group. In recent times, possibility of multiple factors other than atopy should be kept in mind while thinking of the associating or implicating factors which will lead to proper management of this pigmentary disorder.
Keywords: Alba, central India, children, hypopigmented patches, Pityriasis
How to cite this article:
Ramteke KA, Kar S, Patrick S, Sawant A, Ambhore V. Pityriasis alba: current clinicoepidemiologic scenario in a rural tertiary care hospital in central India. Pigment Int 2022;9:182-7 |
| Introduction | |  |
Pityriasis alba (PA) is a common, benign skin disorder occurring predominantly in children and adolescents. The name Pityriasis refers to fine scale and alba refers to pale color (hypopigmentation).[1] It is characterized by the presence of ill-defined, faintly erythematous patches with fine scaling which eventually subside, leaving behind hypopigmented areas. These lesions are usually located over the face, neck, and shoulders although trunk and upper limbs may also be involved in some patients.[2]
The PA is one of the commonly encountered dermatoses with single-point prevalence of 18.9% in school children in central India.[3] Prevalence of PA is reported more often in males when compared with females.[4] It has been correlated with the low socioeconomic status (SES) of the families to which the patients belong.[5] The exact etiology of PA is not known. The condition is observed more commonly in people with atopic diathesis and has been considered as one of the minor manifestation for atopic dermatitis according to the Hanifin and Rajka criteria for the diagnosis of atopic dermatitis.[6] Other proposed implicating factors include seasonal variation, xerosis, sun exposure, anemia, parasitic infestations, and nutritional deficiencies including low zinc levels.[7] However, the exact etiopathogenesis is yet to be discerned.
The microscopic features of PA are those of a mild, chronic, nonspecific dermatitis with decreased melanin production. There is reduction in melanocytes and melanosomes with no defect in melanosomal transfer to keratinocytes. It results primarily from inflammation involving the epidermis and superficial dermis, which interferes the normal pigmentation, thus resulting in hypomelanosis.[8],[9] Several nonspecific histopathologic features including hyperkeratosis, parakeratosis, acanthosis, spongiosis, and perivascular infiltrates are evident. The histologic changes in the intermediate stage are characterized by the damage to the hair follicle and spongiotic edema. Late-stage PA shows a finding of typical chronic dermatitis and irregularly distributed melanization.[10]
However, a lot is yet to be ascertained thanks to the ever evolving newer studies and the epidemiologic associations in the etiopathogenesis. In view of this, we conducted a study to describe the clinical and epidemiologic characteristics of PA in central India and to elucidate the role of various suggested etiologic factors in this population group.
| Materials and Methods | | |
An observational study was conducted in the outpatient Department of Dermatology, Venereology, and Leprosy in a rural tertiary care hospital situated at central India. A total of 100 patients diagnosed clinically as PA visiting to Department of Dermatology, Venereology, and Leprosy were enrolled for the study. An ethical clearance was taken from the Institutional Ethics Committee prior to initiation of the study (as per letter no: MGIMS/IEC/SKIN/91/2017). An informed consent was also taken from the participant’s parents (as participants are minor) regarding their willingness for participation in study.
Inclusion criteria were clinically diagnosed cases of PA, age group of 2 to 15 years, and patients whose parents gave written informed consent for willingness to participate in the study (as the patients are minor). Exclusion criteria were patients whose parents are not willing to give consent to participate in this study.
A structured predesigned, pretested questionnaire was used to collect data related to clinicoepidemiologic profile. The collected data were encoded and entered electronically in a computer using Excel worksheet 2010 version.
Statistical analysis was carried out by using descriptive statistics and software used in the analysis were SPSS 22.0 (Polar Engineering and Consulting, USA) version and GraphPad Prism 7.0 (GraphPad Software Inc. 1992–2012). Data were expressed in frequencies and percentages.
| Results | | |
Most common age group of patients observed [Table 1], Figure 1] was 6 to 10 years (42%) followed by 11 to 15 years (33%) and 2 to 5 years (25%). Out of all the patients, 54% were males [Table 2]. Thus, a slight male preponderance was observed. The male to female ratio was 1.17:1.
In our study, maximum patients, owing to the regional ethnicity, had Fitzpatrick skin type IV (87%). It was followed by type III (7%) and type V (6%) [Table 3], Figure 2]. | Figure 2 Distribution of patients according to the Fitzpatrick skin type.
Click here to view |
Maximum number of patients belonged to SES class III, that is, lower middle (50%) followed by SES class IV, that is, upper lower (37%) and class V, that is, lower (10%) according to the modified Kuppuswamy SES scale (2018) [Table 4].
The age of onset of PA lesions was reported most commonly ranging from 6 to 10 years of age [Table 5]. Clinical characteristics revealed that maximum patients had 0 to 5 patches (48%). About 45% patients had 6 to 10 patches and 7% had 11 to 15 patches of PA [Table 6]. The patches were oval to round in shape with ill-defined margins [Figure 3] and [Figure 4]. | Figure 3 Clinical image of patient with Pityriasis alba having multiple hypopigmented, round to oval patches with ill-defined borders over cheeks.
Click here to view |
 | Figure 4 Clinical image of patient with Pityriasis alba having multiple hypopigmented patches over cheeks and chin.
Click here to view |
Disease duration of 1 to 2 months was found in 36% of the patients followed by duration of less than a month reported in 35% of patients [Table 7]. Rest of the patients had duration more than 2 months. | Table 7 Distribution of patients according to disease duration in months
Click here to view |
The cheeks were the most common site to be involved (patches were present on cheeks in 99% of patients) followed by forehead (46%), nose (25%), and chin (1%). No extrafacial sites were involved [Table 8].
Associated features such as itching, scaling, and erythema were present in 18%, 98%, and 1%, respectively. Pallor was observed in 28% patients. However, due to financial restraints, further blood investigations were not performed.
A significant history of atopy was elucidated in only 21% of patients and was absent in the rest of the patients. About 6% patients showed positive family history of having PA and 14% having a positive history of atopy in first-degree family members.
All the patients (100%) were vaccinated as per the age in accordance with the National Immunization Program schedule.
The parents denied of any significant seasonal variation in any of the patients.
| Discussion | | |
The present study was a cross-sectional study in which 100 patients with the clinical diagnosis of PA presented to the outpatient department of Dermatology, Venereology, and Leprosy in a tertiary rural hospital in central India were included. The study was conducted over a period of 1 year.
According to Sori et al.[11] in 2011, the PA lesions occurred in the age range of 5 months to 14 years (mean of 6.3 years) in children studied by them in Pondicherry. Kamal et al.[12] in 2018 found that PA was most commonly reported in the age group of 10 to 19 years (43.7%). In our study most common age group of patients observed was 6 to 10 years.
Vinod et al.[4] in their study in 2002 found that 115 (57.5%) were males and 85 (42.5%) were females. The male to female ratio was 1.35:1. In a study conducted by Anand et al.[13] in 2012, in school children of Kalkunte, Agrahara, PA was reported more common in boys (52.8%) when compared with girls (41.1%). We got similar findings in accordance with these studies. In our study, 46% (n = 46) were females, whereas 54% (n = 54) were males. The male to female ratio was 1.17:1.
Inanir et al.[5] in 2002 conducted a study to determine the prevalence of skin conditions and associated socioeconomic factors in primary school children in Turkey and found that PA was significantly higher in the school children with poor socioeconomic conditions. Jawade et al.[14] in 2015 concluded that PA was found to be present in 4.16% of all the patients studied and the higher incidence may be because of the poor socioeconomic factors. In our study, maximum number of patients belonged to SES class III, that is, lower middle (50%) followed by SES class IV, that is, upper lower (37%) and class V, that is, lower (10%) according to the modified Kuppuswamy SES scale (2018). Further explanation for our findings about the SES could be that this study is conducted in a rural tertiary care hospital. Therefore, we did not get any patients belonging to the very affluent class I and got only 3% patients belonging to class II.
The duration of the PA lesions varied from less than a month to more than 1 year, with majority of the patients having complaints of less than 6 months duration.[14],[15] In our study, the age of onset was most commonly observed to be 6 to 10 years with mean duration of 1 to 2 months. Thus, it can be concluded that lesions of PA have a relative variable duration that may be either due to improper treatment or due to the self-limiting course of the condition.
Elshafey et al.[15] in 2012 found that single patch was reported in 35.5% of patients, whereas more than one patch was reported in rest 64.5% patients. In addition, itching was present in only 23% of the studied patients and it was absent in the rest. Similarly, a study conducted in 2002[4] showed varied number of lesions, with majority of patients (60.5%) having two to five lesions and a history of increased itching in the lesions on exposure to sunlight was obtained. In our study, we found patients having patches ranging in number from 2 to 14 with maximum patients having zero to five patches (48%). Forty-five percent patients had 6 to 10 patches and 7% had 11 to 15 patches of PA. In our study, only 18% patients showed history of itching and it was absent in the rest. None of our patients showed any variation with sun exposure.
Sori et al.[11] in 2011 found history of atopy present in 3 (10.7%) patients out of 28 patients of PA. Soni et al.[16] in 2017 found that out of 82 cases of PA, 48 cases (58.36%) had a history of atopy. In our study, we found positive history of atopy in the form of atopic dermatitis, allergic asthma, and allergic rhinitis in 21% of patients and positive family history of atopy in 14% of patients.
Presence of anemia was reported in 16.5%[4] of the cases and 21.95%[16] of the cases in two different studies. In our study, anemia was evident in the form of mild grade pallor present in 28% of our patients. However, due to financial constraints, further blood investigations could not be performed.
According to Sori et al.[11] in 2011, almost all the patients with PA had lesion over face with no other body surface involvement. Kamal et al.[12] in 2018 found face as the most common site (72.7%) followed by arms (13.5%), neck, and chest (4.9% each). In our study, all of the patients had lesions over face only and no other body part was involved. Cheeks were the most common site involved (99% patients) followed by forehead (46%), nose (25%), and chin (1%). The key findings of few major studies have been summarized [Table 9].
Moreno-Cruz et al.[17] in 2012 studied patients with PA and found that maximum patients in their study were of Fitzpatrick phototype V (75%) and the rest were of phototype IV (25%). In our study, maximum patients were of Fitzpatrick phototype IV (87%). Others were of Fitzpatrick phototype III (7%) and phototype V (6%). We did not get any patients of phototypes I, II, and VI because of the ethnicity of this geographical region. Moreover, sunlight makes the lesions of PA more apparent, which is especially true in individuals with higher Fitzpatrick skin types who tan more easily; especially, if they are more likely to remain in the sun for a longer duration.
| Conclusion | | |
We concluded that PA still remains one of the less studied but highly prevalent dermatologic concern in the pediatric age group. Slight male preponderance was observed and most of the patients belonged to lower middle and upper lower socioeconomic classes. The role of poor living conditions needs to be further studied in details. History of atopy was present in 21% cases. Family history was positive in 6% of the patients. However, no seasonal variation was documented that could be due to the increasing concern of the parents and immediate presentation to health-care facility and prompt treatment. This paves a way to further evaluate the various emerging causative factors.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Givler DN, Basit H, Givler A. Pityriasis alba. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021. PMID: 28613715.  |
| 2. | Blessmann Weber M, Sponchiado De Avila LG, Albaneze R, Magalhães De Oliveira OL, Sudhaus BD, Cestari TF. Pityriasis alba: a study of pathogenic factors. J Eur Acad Dermatol Venereol 2002;16:463-8. |
| 3. | Upendra Y, Sendur S, Keswani N, Pallava A. Prevalence of dermatoses among the tribal children studying in residential schools of South Chhattisgarh, India. Indian J Paediatr Dermatol 2018;9:15-20. |
| 4. | Vinod S, Singh G, Dash K, Grover S. Clinico epidemiological study of pityriasis alba. Indian J Dermatol Venereol Leprol 2002;68:338-40. [ PUBMED] [Full text] |
| 5. | Inanir I, Sahin MT, Gunduz K, Dinc G, Turel A, Ozturkcan S. Prevalence of skin conditions in primary school children in Turkey: differences based on socioeconomic factors. Pediatr Dermatol 2002;19:307-11. |
| 6. | Hanifin JM, Rajka G. Diagnostic features of atopic dermatitis. Acta Derm Venereol 1980;92:44-7. |
| 7. | Elesawy FM, Akl EM, Abdel Halim WA. Zinc has a role in pathogenesis of pityriasis alba. Indian J Paediatr Dermatol 2020;21:178-83. [Full text] |
| 8. | Sripada R, Bondada N, Bonam J et al. An updated review on Pityriasis alba. World J Pharm Res 2014;3:2162-71. |
| 9. | Lin RL, Janniger CK. Pityriasis alba. Cutis 2005;76:21-4. |
| 10. | Lee D, Kang JH, Kim SH, Seo JK, Sung HS, Hwang SW. A case of extensive pityriasis alba. Ann Dermatol 2008;20:146-8. |
| 11. | Sori T, Nath A, Thappa D, Jaisankar T. Hypopigmentary disorders in children in South India. Indian J Dermatol 2011;56:546-9. [ PUBMED] [Full text] |
| 12. | Kamal A, Almansour B, Almatrood A, Alshammari T, Alshammari R. Prevalence and awareness of Pityriasis alba in Hail − Saudi Arabia. Int J Adv Res 2018;6:1100-8. |
| 13. | Anand BK, Marwaha MPS, Prakash B et al. Prevalence of skin disorders in school children. Internet J Health 2012;13:1-4. |
| 14. | Jawade S, Chugh V, Gohil S, Mistry A, Umrigar D. A clinico-etiological study of dermatoses in pediatric age group in tertiary health care center in South Gujarat region. Indian J Dermatol 2015;60:635. [ PUBMED] [Full text] |
| 15. | Elshafey WSR, Fiala LA, Mohamed RW, Ismael NA. The distribution and determinants of Pityriasis alba among elementary school students in Ismailia city. J Am Sci 2012;8:444-9. |
| 16. | Soni B, Raghavendra K, Yadav D, Kumawat P, Singhal A. A clinico-epidemiological study of hypopigmented and depigmented lesions in children and adolescent age group in Hadoti region (South East Rajasthan). Indian J Paediatr Dermatol 2017;18:9-13. [Full text] |
| 17. | Moreno-Cruz B, Torres-Álvarez B, Hernández-Blanco D, Castanedo-Cazares JP. Double-blind, placebo-controlled, randomized study comparing 0. 0003% calcitriol with 0. 1% tacrolimus ointments for the treatment of endemic Pityriasis alba. Dermatol Res Pract 2012;2012:303275. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]
|
Search Pubmed for