CASE REPORT
Pityriasis Alba with Poliosis
Tayyaba Gul Malik1, Muhammad Khalil1 and Muhammad Moeen Bhatti2
ABSTRACT
Pityriasis alba is a skin disease, commonly seen in children and young adults. This case presents the ocular association
of this disease in a 10 years old Pakistani male. Ocular features in this case were poliosis, tilted disc, high myopia and
chorioretinal degeneration. Tilted discs and high myopia can be coincidental but poliosis and decreased pigment in retinal
pigment epithelium are closely related with the hypopigmentation seen in this disease.
Key Words: Pityriasis alba. Poliosis. Vitiligo. Retina.
INTRODUCTION
Pityriasis alba is a self limiting dermatosis. It is regarded
as a manifestation of atopic dermatitis. However, non-
atopic individuals are also known to have this disease.1
It can occur in any race but more problematic in dark
skinned individuals. In an audit at Hamdard University
Hospital, Karachi, the frequency of this disorder was
found to be very low as compared to the other
dermatological diseases.2 About 4.9% patients had
pityriasis alba in an epidemiological study presented by
Sharma in Indian Punjab.3
Lesions of pityriasis alba are characterized by rounded,
oval or irregular plaque with indistinct margins. The
cause of this disease is still unknown. However, many
contributory factors are mentioned in the literature
including, temperature, humidity, hygiene and altitude.
No treatment is usually required and the disease is
self resolved within months or a year. This case report
presents the ocular features which were found in
association with pityriasis alba.
CASE REPORT
A 10 years old Pakistani child came to the out-patient
department with history of decreased vision in both eyes
for 2 years. He had been prescribed glasses but the
compliance was poor. There was no irritation and
redness in both eyes. Systemic history revealed whitish
patches on the skin, especially on the face which
appeared 2 years back. He had two brothers and one
sister and all were normal with no ocular and systemic
disease.
1 Department of Ophthalmology, Lahore Medical and Dental
College, Lahore.
2 Department of Ophthalmology, Ghurki Trust Teaching
Hospital, Lahore.
Correspondence: Dr. Tayyaba Gul Malik, 649-N, Samanabad,
Lahore-25.
E-mail: tayyabam@yahoo.com
Received: November 27, 2012; Accepted: March 16, 2013.
138
On examination, he was an average built young boy who
was well oriented in time and space. He was orthophoric
and had hypertelorism. There was recent onset poliosis
(Figure 1), otherwise the eyelids were normal with no
signs of blepharitis. Autorefraction showed -12.75 DS
with -1.75 DC at 12 in right eye and -11.5 DS with -2.00
DC at 180 in his left eye. His best corrected visual
acuity was 6/36 with -5.00 DS in each eye. Anterior
segment showed no abnormality. On dilated fundus
examination, there were tilted discs in both eyes. Large
choroidal vessels were visible due to myopic chorio-
retinal degeneration which was also involving the
macular region.
General physical examination showed normal vital
signs. Skin showed hypopigmented lesions on the face
especially around the mouth, chin and on the cheeks.
They were round or oval and margins were not well
defined. The lesions showed no signs of inflammation
but there was history of mild erythema prior to the
appearance of these white patches. There was no
history of eczema and asthma. There were no signs of
thyroid disease, lymphoma and pernicious anaemia.
Chest X-ray, CBC and liver function tests were normal.
The patient was referred to dermatology department for
management. Biopsy was not required for diagnosis and
not done in this patient. Clinical features helped in
making the diagnosis.
DISCUSSION
Pityriasis is derived from a Greek word which means
scaling and flaking. Alba means white in Latin. The
patches are not entirely depigmented in this condition.4
It is a common disorder of children and young adults and
there is increased occurrence in pre-adolescent children.
Whites are more prone than blacks. Both gender are
equally affected. In this particular case, age of the child
was 10 years.
Etiology of this disease is still unknown but there is a
common association of pityriasis alba with atopy or a
strong family history of atopy. It was not elicited in this
Journal of the College of Physicians and Surgeons Pakistan 2014, Vol. 24 (2): 138-140
Pityriasis alba with poliosis
Figure 1: Patient with poliosis.
Figure 2: Hypopigmentation around the mouth.
case and also not in close family members except a
history of asthma in one of his paternal uncles.
There are certain possible risk factors. More common
are xerosis and mineral deficiency. Sun exposure makes
these lesions more prominent.5 Some studies have
shown that it is associated with copper deficiency.6
In this patient, no history or clinical evidence of xerosis
was found. Serum mineral analysis could not be
performed.
Three stages of this disease are identified: erythema,
scaling and hypopigmentation. Mild scaling and hypo-
pigmentation are the clinical features which are more
commonly seen when the patients seek medical advice.
Lesions are more prominent around the mouth, cheeks
and chin. This patient had hypopigmented lesions on the
face especially around the mouth, cheeks and chin as
shown in Figure 2. Scaling of the lesions could not be
made out. It might be because of the reason that scaling
is more common in dry winter while hypopigmentation
becomes more prominent in summer. Usually no
treatment is required for hypopigmentation and patches
heal with time.7
There is a large list of hypopigmented lesions of the skin
but few are associated with the ocular manifestations.
Skin depigmentation is seen in Naevus depigmentosus,
cutaneous T-cell lymphoma, vitiligo and pityriasis rosea.
Naevus depigmentosus is present at birth or before 3
years. It is a single well demarcated lesion on the trunk
with no ocular findings.8 There are reports indicating
ocular involvement in cutaneous T-cell lymphoma but
this disease is associated with indolent inflammatory
response which was absent in our patient. In pityriasis
rosea pink, salmon pink or brown coloured patches are
found on the extremities. The extremities were normal in
Journal of the College of Physicians and Surgeons Pakistan 2014, Vol. 24 (2): 138-140
this particular patient and the depigmentation was not
pink or brown.
Ocular features in this case were poliosis, tilted disc,
high myopia and chorioretinal degeneration. We could
not find any of these in any case of pityriasis alba
reported so far in the literature.
It was tried to rule out the other causes of poliosis.
Common ocular causes of poliosis are chronic
blepharitis, sympathetic ophthalmia and uveitis.9 All of
these conditions were absent in this patient. Systemic
associations of poliosis include Vogt Koyanagi Harada
syndrome, Wardenburg syndrome, vitiligo, Marfans
syndrome and Tuberous sclerosis. Typical skeletal and
soft tissue abnormalities associated with Marfan's
syndrome were absent in this patient. Absence of
adenoma sebaceum, cafe au lait spots, ash leaf spots,
shagreen patches and other visceral and neurological
signs of tuberous sclerosis ruled out this condition.
There were no clinical features suggestive of Warden-
burg syndrome and VKH syndrome. In vitiligo, hypo-
pigmentation is well demarcated while the margins of
hypopigmentation in that patient were blurred. We
searched the literature but did not find any case showing
association of poliosis with pityriasis alba.
Tilted disc and high myopia could be chance asso-
ciations. Pigment deficiency in the retinal pigment
epithelium can be either due to myopic degeneration or
because of the fact that number of melanosomes
are deficient in the lesions of skin of pityriasis alba.
Literature reveals that histologically there is no signifi-
cant difference in the number of melanocytes between
the lesional and the normal skin.10 However, the number
and size of melanosomes are reduced in these lesions.
To the authors knowledge, this is the first report of
pityriasis alba with poliosis. Poliosis can be caused by
damage to the melanosomes which is histologically
evident in the literature. This decrease in the number of
melanosomes might be induced by erythema which was
seen in the first stage of pityriasis alba. Further research
on the ocular associations of this disease is required.
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Tayyaba Gul Malik, Muhammad Khalil and Muhammad Moeen Bhatti
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Journal of the College of Physicians and Surgeons Pakistan 2014, Vol. 24 (2): 138-140