Evaluation of New Onset Hypopigmentation and Other Dyschromias

Featuring Ginette A. Okoye, MD, FAAD

In one of the morning breakout sessions, Dr. Ginette Okoye gave an enlightening presentation on hypopigmentation and other dyschromias. When you see hypopigmentation , Dr. Okoye cautioned, “ don’t automatically diagnose post inflammatory hypopigmentation”. The first decision to make in the approach to these patients is whether they have hypopigmentation or depigmentation. The best way to answer this is through use of a wood’s lamp. Depigmentation happens when melanocytes are no longer functioning or gone, such as in the case of vitiligo. Clues to diagnosis of hypopigmented conditions rely on the distribution, morphology and symptoms of these presentations.

Depigmentation happens when melanocytes are no longer functioning or gone, such as in the case of vitiligo.

Next, Dr. Okoye used case presentations to illustrate various presentations of hypopigmentation in the facial region. While seborrheic dermatitis tends to be salmon colored or erythematous in Caucasian individuals, in patients of color this condition can present as hypopigmentation. As topical steroids may lead to hypopigmentation, in these patients you may want to avoid topical steroids for treatment. An interesting condition currently identified as “facial discoid lesions” was illuminated by Dr. Okoye. Facial discoid lesions present as hypopigmented macules and patches on the face and scalp. These can be described as “copper colored” and is a diagnosis by exclusion. It is most common in black men over the age of 45 who are from the continent of Africa. It is often misdiagnosed as post-inflammatory hypopigmentation.

While seborrheic dermatitis tends to be salmon colored or erythematous in Caucasian individuals, in patients of color this condition can present as hypopigmentation.

Dr. Okoye went on to discuss presentations of hypopigmented lesions on the trunk. A common presentation in young women is progressive macular hypopigmentation which is asymptomatic. It is likely due to P.acnes in the hair follicle interfering with the function of melanocytes. Mycosis fungoides will present in the bathing suit distribution also known as the “double covered area” or where two layers of clothing cover. Mycosis fungoides is more common in African Americans and has higher mortality rates. It typically presents as hypopigmented patches and plaques with or without atrophy. It is important to biopsy hypopigmented areas as well as normal appearing skin to confirm this diagnosis. Dr. Okoye recommends performing two or more broad shave biopsies to include hypopigmented and adjacent normal looking skin that is not sun exposed. Additional truncal presentations of hypopigmented lesions Dr. Okoye presented include syphilitic leukoderma and tinea versicolor.

Finally, Dr. Okoye discussed hypopigmentation on the extremities. One of the most common presentations include “Bier spots” which are physiologic anemic macules. A rarer presentation of hypopigmentation is chronic arsenic toxicity. Additional clinical features in these patients include transverse bands on nails and palmar hyperkeratosis. Typical patients include those who have had chronic exposure to pesticides, herbicides, copper and lead smelting and wood treatment. Additional conditions Dr. Okoye presented include leprosy, sarcoidosis, steroid induced hypopigmentation.