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Little white spots: an approach to hypopigmented macules
  1. P A Lio
  1. Dr P A Lio, Children’s Hospital Boston, Fegan 6 Dermatology, 300 Longwood Avenue, Boston, MA 02115 USA; peter.lio{at}

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Loss of pigment, either partial (hypopigmentation) or complete (depigmentation), can have a profound psychological impact, perhaps seemingly out of proportion for something that is almost exclusively benign.1 Remarkably, hypopigmentation has been referenced in many ancient religious texts, often in the context of being a curse or contagious disease, firmly securing this cutaneous malady at the very deepest level of culture.2 A compelling illustration of this occurs in the Old Testament when Miriam speaks against Moses and is punished thusly: “… suddenly Miriam became leprous, as white as snow.”3 It is difficult to imagine a more wicked association for a skin disease than such an execration. Although the vast majority of hypopigmentation encountered in the modern world is neither contagious nor dangerous, fear, anxiety and uncertainty continue to surround this problem for patient and physician alike.

An exhaustive list of causes of hypopigmentation and depigmentation would contain many rare and obscure entities, but in this review the focus will be limited to three of the most common causes of acquired loss of pigment in children.4 By closely examining pityriasis alba, pityriasis (tinea) versicolor, and vitiligo, some of the fear, anxiety and uncertainty may be dispelled and, even if they cannot be cured, simple understanding may provide some relief.


Pityriasis alba is a common, benign form of localised, often slightly scaly areas of hypopigmenation, usually on the head, neck, and upper extremities of children.5 While the pathogenesis is unclear, many studies seem to support the idea that it is a form of low-grade eczematous dermatitis.6

Pityriasis versicolor is sometimes called tinea versicolor, but “pityriasis” derives from the Greek for “grain husk” or “bran” and descriptively refers to the flaky, bran-like scale of this extremely common superficial fungal infection.7 Figure 1 is a photograph of bran …

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  • Competing interests: None.

  • Patient consent: Informed parental/guardian consent was obtained for figures 2–7.