BMJ 2017;356:i6534 doi: 10.1136/bmj.
i6534 (Published 2017 January 05)
Practice
PRACTICE POINTER
An approach to hypopigmentation
Jeremy P Hill general practitioner with special interest in dermatology , Jonathan M Batchelor
2
consultant dermatologist
1
Whyburn Medical Practice, Hucknall, Nottingham UK; 2Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
Around 1 in 20 people have at least one hypopigmented macule.1
Patients may worry about pale patches and links to other disease.
Hypopigmentation can be upsetting, particularly if visible. For
people with darker skin, hypopigmentation may also result in
stigma.2 Most causes of hypopigmentation are not serious, can
be diagnosed clinically and may be treatable. This article aims
to help non-specialists assess and treat patients with
hypopigmented patches, focusing on the commonest conditions
and mentioning rarer but important conditions where specialist
referral may be necessary.
What features in the history and
examination should I focus on?
Consider demographics:
• Age—Pityriasis alba typically affects children, pityriasis
versicolor usually affects young adults, vitiligo affects
people of any age but commonly starts before the age of
30 years.
• Race—Hypopigmented patches occur in all racial groups
but are much more noticeable in those with darker skin;
post-inflammatory hypopigmentation (occurring after a
rash has resolved) is also more common in people with
darker skin. Leprosy should be considered in patients from
areas of the world where it is still prevalent.
Ask the patient to describe how the pale patch began, how it
has developed and whether there are any other patches. Discuss
the impact that the condition is having on the patient’s self
confidence and on wider aspects of their life.
Clinical examination will help to determine:
• Distribution—Pityriasis alba usually affects the head, neck,
and arms; pityriasis versicolor commonly affects the trunk;
vitiligo typically affects the face, genitalia, hands and feet,
and flexures. Remember that a solitary patch may be the
start of more patches.
• Symmetry—Pityriasis versicolor and vitiligo are usually
symmetrical.
Correspondence to: J P Hill jeremy.hill@gp-c84124.nhs.uk
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PRACTICE
1
• Surface change—Fine scale (elicited by scraping the skin
with a scalpel) suggests pityriasis versicolor; pityriasis alba
has an eczematous surface appearance.
• Evidence of other inflammatory skin disease—Coexistent
or preceding inflammatory rashes (such as eczema or lupus)
raise the possibility of post-inflammatory
hypopigmentation.
What are the common causes of
hypopigmention?
Vitiligo (fig1 )
How does it present?
This autoimmune condition causes chalky-white, usually
symmetrical, patches of skin.3 Early, active patches may have
less well defined edges and may not have lost all pigmentation.4
Vitiligo affects up to 1% of the population. Onset usually occurs
gradually before the age of 30 years, but it can occur at any age
and may be rapid. There may be a family history of vitiligo or
other autoimmune conditions such as thyroid disease or alopecia
areata.5 6 As well as reduced self confidence, some patients may
be socially ostracised and experience difficulties with
employment opportunities and marriage prospects.7 The
diagnosis is usually clinical.
What treatments are available?
There is evidence from randomised controlled trials that some
treatments work well6 and that early intervention may improve
response to treatment.8 Small trials have shown that potent9 and
ultrapotent10 topical corticosteroids applied once daily can cause
successful repigmentation, as can 0.1% tacrolimus ointment11
applied twice daily for six months. Advise patients to use high
factor sunblock to prevent sunburn and to reduce tanning of
normal skin, which makes vitiligo more noticeable. Offer referral
to cosmetic camouflage services (www.changingfaces.org.uk).
Refer patients in whom the vitiligo has spread rapidly (over a
few months) or has not responded to three months of topical
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BMJ 20172017;356:i6534 doi: 10.1136/bmj.i6534 (Published 2017 January 05)
What you need to know
• In many cases, non-specialists can form a working diagnosis for hypopigmentation from the history and examination alone
• Common causes include vitiligo, post-inflammatory hypopigmentation, pityriasis versicolor, pityriasis alba, and halo naevi
• Take time to understand how skin changes affect confidence as well as work and home life
treatment. Patients with extensive vitiligo (>10% of body surface
area, which equates to slightly more than the area of one whole
arm and hand) or vitiligo of exposed sites that has not responded
to other treatment may benefit from phototherapy.
Post-inflammatory hypopigmentation (fig 2 )
How does it present?
Pale patches may occur on the skin after any cause of
inflammation such as discoid eczema, psoriasis, cutaneous lupus,
sarcoidosis, thermal burns, or cryotherapy. Patients with dark
skin are particularly prone to post-inflammatory
hypopigmentation or hyperpigmentation.
How is it treated?
Post-inflammatory hypopigmentation usually resolves
spontaneously once the underlying condition has been
successfully treated but it may take several months.
Pityriasis versicolor (fig 3 )
How does it present?
This fungal infection, typically with Malassezia species, causes
flat, scaly discolouration of the skin on the trunk and limbs,
usually in young adults. It occurs more often in hot climates.
Diagnosis is usually made clinically but taking a surface skin
scraping for mycology (using a scalpel blade) can help to
confirm the diagnosis when clinical signs are subtle.
How is it treated?
Topical ketoconazole 2% shampoo (once daily for five days)
is usually effective. Selenium sulphide 2.5% shampoo (once
daily for seven days) is an alternative.12 Explain that colour
changes in affected skin may last for many months after
treatment and are sometimes permanent. Further treatment is
required only if the patches are still scaly when stretched or
scratched.13
Pityriasis alba (fig 4 )
How does it present?
This mild, superficial eczema causes scaly (pityriasis), white
(alba) patches, typically on the cheeks, chin, and arms of up to
5% of children, with an equal sex incidence. Patients often
present after a sunny holiday, because tanning of the surrounding
skin makes the pale patches more obvious. Diagnosis is usually
clinical. Skin scrapings for mycology will be negative.
How is it treated?
Pityriasis alba resolves spontaneously. Advise patients that
regular emollients will improve dryness. A mild topical steroid
(such as 1% hydrocortisone) will reduce inflammation.
Halo naevus (Sutton’s naevus) (fig 5 )
How does it present?
A halo naevus occurs when a benign melanocytic naevus (mole)
undergoes destruction by the immune system. The reasons for
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Page 2 of 6
PRACTICE
this are unknown. As the mole is destroyed, surrounding
melanocytes are damaged and a rim of pale skin develops around
the mole. Over a period of several months the original naevus
disappears, leaving a hypopigmented macule. This gradually
returns to its normal colour over months or years.
Halo naevi occur in around 1% of children and young adults.
Males and females are equally affected. Halo naevi commonly
present in the summer when tanning of the surrounding skin
makes the halo more prominent.
Halo naevi can rarely be triggered by a malignant melanoma
elsewhere on the body,14 so full skin examination is important.
Also, some malignant melanomas can develop a halo around
them, so consider referral to a dermatologist if there is diagnostic
doubt. Patients with halo naevi do not require treatment, only
reassurance. Offer advice about sun protection as the halo
contains no protective melanin and will burn easily.
Less common causes of hypopigmention
(fig 6 )
Contributors: Both authors contributed equally to this article.
Competing interests: We have read and understood BMJ policy on
declaration of interests and have relevant interests to declare.
Provenance and peer review: Commissioned; externally peer reviewed.
1 Vanderhooft SL, Francis JS, Pagon RA, Smith LT, Sybert VP. Prevalence of
hypopigmented macules in a healthy population. J Pediatr 1996;356:355-61. doi:10.1016/
S0022-3476(96)70066-5 pmid:8804323.
2 Pandve HT. Vitiligo: is it just a dermatological disorder?Indian J Dermatol 2008;356:40-1.
doi:10.4103/0019-5154.39745 pmid:19967022.
3 Ezzedine K, Eleftheriadou V, Whitton M, van Geel N. Vitiligo. Lancet 2015;356:74-84.
doi:10.1016/S0140-6736(14)60763-7 pmid:25596811.
4 Benzekri L, Gauthier Y, Hamada S, Hassam B. Clinical features and histological findings
are potential indicators of activity in lesions of common vitiligo. Br J Dermatol
2013;356:265-71. doi:10.1111/bjd.12034 pmid:22963656.
5 Ingordo V, Cazzaniga S, Raone B, et al. Circulating autoantibodies and autoimmune
comorbidities in vitiligo patients: a multicenter Italian study. Dermatology 2014;356:240-9.
doi:10.1159/000357807 pmid:24603479.
6 Vrijman C, Kroon MW, Limpens J, et al. The prevalence of thyroid disease in patients
with vitiligo: a systematic review. Br J Dermatol 2012;356:1224-35. doi:10.1111/j.1365-
2133.2012.11198.x pmid:22860695.
7 Pahwa P, Mehta M, Khaitan BK, Sharma VK, Ramam M. The psychosocial impact of
vitiligo in Indian patients. Indian J Dermatol Venereol Leprol 2013;356:679-85. doi:10.
4103/0378-6323.116737 pmid:23974584.
8 Hallaji Z, Ghiasi M, Eisazadeh A, Damavandi MR. Evaluation of the effect of disease
duration in generalized vitiligo on its clinical response to narrowband ultraviolet B
phototherapy. Photodermatol Photoimmunol Photomed 2012;356:115-9. doi:10.1111/j.
1600-0781.2012.00648.x pmid:22548391.
9 Wazir SM, Paracha MM, Khan SU. Efficacy and safety of topical mometasone furoate
0.01% vs. tacrolimus 0.03% and mometasone furoate 0.01% in vitiligo. J Pak Assoc
Dermatol 2010;356:89-92.
10 Khalid M, Mujtaba G, Haroon TS. Comparison of 0.05% clobetasol propionate cream and
topical Puvasol in childhood vitiligo. Int J Dermatol 1995;356:203-5. doi:10.1111/j.1365-
4362.1995.tb01570.x pmid:7751099.
11 Radakovic S, Breier-Maly J, Konschitzky R, et al. Response of vitiligo to once- vs.
twice-daily topical tacrolimus: a controlled prospective, randomized, observer-blinded
trial. J Eur Acad Dermatol Venereol 2009;356:951-3. doi:10.1111/j.1468-3083.2009.03138.
12
x pmid:19496898.
Hald M, Arendrup MC, Svejgaard EL, Lindskov R, Foged EK, Saunte DM. Danish Society
of Dermatology. Evidence-based Danish guidelines for the treatment of Malassezia-related
skin diseases. Acta Derm Venereol 2015;356:12-9. doi:10.2340/00015555-1825 pmid:
24556907.
13 Renati S, Cukras A, Bigby M. Pityriasis versicolor. BMJ 2015;356:h1394. doi:10.1136/
bmj.h1394. pmid:25852089.
14 Pellegrini JR, Wagner RF Jr, , Nathanson L. Halo nevi and melanoma. Am Fam Physician
1984;356:157-9.pmid:6464957.
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BMJ 20172017;356:i6534 doi: 10.1136/bmj.i6534 (Published 2017 January 05) Page 3 of 6

PRACTICE

Education into practice

• Pale skin patches are a source of anxiety and distress to patients. Have you asked your patients how their condition affects them and
whether it interferes with their life?
• Do you know where to direct someone for support with a condition such as hypopigmentation? (see useful resources box)
• When you offer a trial of treatment for hypopigmentation, do you establish that the patient understands how long they will be treated
for and how success will be measured?

Useful resources
• DermNet New Zealand (www.dermnetnz.org)—Freely accessible website with information on many of the conditions mentioned in
this article
• Changing Faces (www.changingfaces.org.uk)—Offers consultations on cosmetic camouflage products for patients with vitiligo and
other skin conditions
• The Vitiligo Society (www.vitiligosociety.org.uk)—Charity offering advice and support to patients with vitiligo

How patients were involved in the creation of this article

A patient with vitiligo reviewed this article and suggested improvements which have been incorporated into the final version.

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PRACTICE

Figures

Fig 1 Symmetrical depigmented patches of vitiligo

[Image: Custom medical stock photo/SPL]

Fig 2 Post-inflammatory hypopigmentation after treatment for psoriasis

[Image: P Marazzi/SPL]

Fig 3 Slightly scaly, hypopigmented patches on the trunk are typical of pityriasis versicolor
[Image: Phanie/Alamy]

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Fig 4 Slightly scaly, hypopigmented patches on a child’s face in pityriasis alba

[Image: Regionalderm.com]

Fig 5 Benign melanocytic naevus with surrounding hypopigmentation (halo naevus)

[Image: Harout Tanielian/SPL]

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PRACTICE

Fig 6 Less common causes of hypopigmentation

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