Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current Issue
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Snippets
Special Article
Specialty Interface
Studies
Study Letter
Study Letters
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Review and Meta-Analysis
Systematic Reviews and Meta-analyses
Systematic Reviews and Meta-analysis
Tables
Technology
Therapeutic Guideline-IADVL
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
Therapy Letters
View Point
Viewpoint
What’s new in Dermatology
View/Download PDF

Translate this page into:

Observation Letter
ARTICLE IN PRESS
doi:
10.25259/IJDVL_273_2022

Idiopathic guttate hypomelanosis-like macules co-localizing to sites of topical photochemotherapy for vitiligo in children: Clinical and dermoscopic findings

Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India
Corresponding author: Dr. Neetu Bhari, Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India. drntbhari@gmail.com
Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Mehta N, Yadav D, Bhari N. Idiopathic guttate hypomelanosis-like macules co-localizing to sites of topical photochemotherapy for vitiligo in children: Clinical and dermoscopic findings. Indian J Dermatol Venereol Leprol doi: 10.25259/IJDVL_273_2022

Sir,

Phototherapy is an effective treatment in children with stable vitiligo and is generally quite safe. However, a rarely reported adverse effect is the development of small well-defined depigmented macules in the areas exposed to ultraviolet radiation. These have been described variably as leucoderma punctatum,1 confetti-like hypopigmentation and idiopathic guttate hypomelanosis-like lesions.2 These macules have not been well characterised, and their dermoscopic features have not been described in detail. They have been reported only in a few case reports and series.1

Five children with stable vitiligo receiving photochemotherapy with topical psoralen followed by sun exposure as a source of ultraviolet A (PUVAsol therapy) for the varying duration were noticed to have multiple small well-defined depigmented macules of size 1–5 mm in and around the vitiliginous skin [Table 1 and Figures 1a–e]. These were restricted to the area which was exposed to photochemotherapy. These macules had started after a few months after initiation of PUVAsol therapy and increased in number as the photochemotherapy was continued, although there was mild to good re-pigmentation in the vitiligo lesions. These new depigmented macules were relatively smaller and brighter white, compared to the chalky white hue and larger size of existing vitiligo lesions. When present within vitiligo patches, their boundaries could be delineated due to different hues of depigmentation.

Table 1:: Patients’ profile and duration of photochemotherapy in the form of topical psoralen followed by sun exposure as a source of ultraviolet A (PUVAsol therapy) for vitiligo
No. Age (years) Duration of phototherapy Discontinued since Photo-sclerosis
1 9 6 months 3 years No
2 14 6 months 6 months No
3 6 14 months Continuing Yes
4 10 10 months Continuing Yes
5 12 4 months Continuing Yes
Figure 1:: Idiopathic guttate hypomelanosis-like macules developing after photochemotherapy. (a-e) Clinical pictures of 5 different patients, showing development of these lesions over vitiligo patches (circle) and surrounding hypopigmented (square), hyperpigmented (solid arrowhead), and normal skin (hollow arrowhead). (f-j) Their respective dermatoscopic pictures showing feathery (blue arrow), amoeboid (black arrow), petaloid (red arrow) and nebuloid margins (star). (Heine Delta 20T, magnification 10×)

On dermoscopy, they had central white structureless areas which lacked a pigmentary network and had multiple convex outpouchings and extensions of their border, suggestive of a petaloid, amoeboid, feathery or nebuloid margin, and a cloudy/popcorn-like appearance [Figures 1f–j].

A biopsy from one lesion located over the hyperpigmented skin of the forearm showed mild papillomatosis and hyperkeratosis, mild flattening of rete ridges, and near absence of basal layer pigmentation in a large section of the slide. The transition between pigmented and non-pigmented basal layer was abrupt and prominent [Figure 2]. No biopsies were performed on other patients.

Figure 2:: Histopathology of idiopathic guttate hypomelanosis-like macules over forearm developing after photochemotherapy. Hyperkeratosis, mild papillomatosis and an abrupt transition of normally pigmented basal cell layer to the zone with a near complete absence of melanin in the basal layer. (Haematoxylin and eosin, ×100)

The presence of lesions exclusively in the distribution of psoralen application and an increasing number of continuing phototherapy supports photochemotherapy as the possible cause for these lesions. Patients three and four had received phototherapy for the maximum duration and had the maximum density of these macules. Patient one had discontinued phototherapy for three years and had the least density.

Small well defined depigmented macules are known to develop after phototherapy in vitiligo,1 psoriasis and mycosis fungoides2 and have been termed as leucoderma punctatum,1 confetti-like hypopigmentation or idiopathic guttate hypomelanosis-like2 (IGH -like) macules. The differential diagnosis of such lesions include punctate vitiligo or vitiligo puncture, also known as confetti vitiligo, and guttate lichen sclerosis [Table 2]. Hypopigmented PUVA keratosis is another differential, which is photo-induced, but the lesions are elevated papules rather than macules.3

Table 2:: Differentials of idiopathic guttate hypomelanosis due to photochemotherapy
Differential Points in favour Points against
Confetti vitiligo – Morphology of small depigmented macules
– Patients already had vitiligo
– At and around otherwise stable and re-pigmenting lesions
– Developed only after phototherapy
Guttate lichen sclerosus – Bright white small macules – Lack of ivory white colour and telangiectasias
– Lack of telangiectasias, comedo-like openings, follicular plugs and black dots in dermatoscopy
Guttate morphea – Small white macules – Depigmented macules instead of hypopigmented or pigmented macules
– Lack of epidermal atrophy, induration or atrophoderma
– Dermatoscopy suggestive of IGH
Achromic verruca plana – Small white clustered lesions – Flat macules, no elevation
Disseminated hypopigmented keratosis – Small white clustered lesions
– Following phototherapy
– Flat macules, no elevation
– Disseminated hypopigmented keratosis might be a hyperkeratotic variant of IGH

Although these lesions have been reported before as IGH-like2 macules, in view of the characteristic dermoscopic features of amoeboid, petaloid, and feathery margins, we opine that these may actually be IGH rather than IGH-like macules.4 The proposed pathogenesis of IGH is multifactorial and implicates photodamage. In fact, IGH has been considered a manifestation of photoaging,5 and occurrence in children in localised areas with long-term intense photo exposure lends credence to the hypothesis that these lesions could be IGH. These IGH-like lesions indicate chronic photodamage and localised premature photoaging in these children. Interestingly, three out of five patients had evidence of chronic phototoxicity in form of photo-sclerosed skin.

Interestingly, even the reported histopathology of these macules is similar to IGH. Both conditions have been reported to show a significant decrease/ near complete absence of melanin and functional melanocytes in the basal and suprabasal layers.1,2,6 A subset of both conditions may show some hyperkeratosis, which when significant may result in clinically raised lesions of hypopigmented keratosis, an entity that probably represents the raised hyperkeratotic variant of IGH.1,3,6 Some patients of both conditions also show epidermal atrophy and flattening of rete ridges.1,6 Interestingly, the focal or patchy presence of melanin, as described by Falabella et al. in leucoderma punctata in 1988, is now a known feature of IGH, described as skip areas.1,7

Although our series is composed of children, IGH-like macules can appear in any age group and is not exclusive to children. Narrow-band ultraviolet B phototherapy can also lead to eruptive IGH-like macules and they are not limited to just psoralen-induced photochemotherapy.2

Photochemotherapy was stopped in all five patients, and they were shifted to mid-potent topical steroids. They were followed for 1–3 months, with no change in either vitiligo patches, IGH-like macules, or extent of re-pigmentation.

In conclusion, it is important to be aware of this rare side effect of phototherapy, as the dyschromia caused by these lesions may offset any benefit of re-pigmentation by phototherapy. As IGH-like macules are dose-dependent and potentially reversible, phototherapy should be discontinued if patients or their guardians perceive a worsening of the appearance of vitiligo lesions due to them.

In this series, we have characterised a rare side effect of photochemotherapy with dermoscopic findings and its putative aetiopathogenesis. We have also highlighted the fact that IGH-like macules following photochemotherapy occur on vitiliginous, re-pigmented and normal skin.

The limitations of this series include a lack of histopathology in all patients and a short follow-up period. There’s a need for further studies with a clinicopathological correlation of lesions at different coloured skin, and with longer follow-up to see the extent of the resolution of these lesions on stopping phototherapy. More robust studies can establish if these IGH-like macules are indeed IGH.

Declaration of patient consent

Patient’s consent not required as patient’s identity is not disclosed or compromised.

Financial support and sponsorship

Nil.

Conflict of interest

There are no conflicts of interest.

References

  1. , , , . Leukoderma punctata. J Am Acad Dermatol. 1988;18:485-94.
    [CrossRef] [PubMed] [Google Scholar]
  2. , , , , . Idiopathic guttate hypomelanosis-like lesions in patients with mycosis fungoides: A new adverse effect of phototherapy. J Eur Acad Dermatol Venereol. 2010;24:1026-30.
    [CrossRef] [PubMed] [Google Scholar]
  3. , , , , , . Hypopigmented keratosis: Is it a hyperkeratotic variant of idiopathic guttate hypomelanosis? Clin Exp Dermatol. 2013;38:526-9.
    [CrossRef] [PubMed] [Google Scholar]
  4. , . Dermoscopic evaluation of idiopathic guttate hypomelanosis: A preliminary observation. Indian Dermatol Online J. 2015;6:164-7.
    [CrossRef] [PubMed] [Google Scholar]
  5. , , , , . Clinical features of idiopathic guttate hypomelanosis in 646 subjects and association with other aspects of photoaging. Int J Dermatol. 2011;50:798-805.
    [CrossRef] [PubMed] [Google Scholar]
  6. , , , , , . Comprehensive understanding of idiopathic guttate hypomelanosis: Clinical and histopathological correlation. Int J Dermatol. 2010;49:162-6.
    [CrossRef] [PubMed] [Google Scholar]
  7. . Skip areas of retained melanin: A clue to the histopathological diagnosis of idiopathic guttate hypomelanosis. Indian J Dermatol. 2014;59:571-4.
    [CrossRef] [PubMed] [Google Scholar]

Fulltext Views
1,211

PDF downloads
6
View/Download PDF
Download Citations
BibTeX
RIS
Show Sections