Presenter: Sheena Nguyen, DO
Dermatology Program: Western University of Health Sciences/Chino Valley Medical Center
Program Director: Navid Nami, DO
Submitted on: December 29, 2016
CHIEF COMPLAINT: White spots all over body
CLINICAL HISTORY: The patient is an eight-year-old girl who presented to the clinic with a three-year history of asymptomatic, hypopigmented macules diffusely spread throughout her body. She denied any preceding illnesses or systemic symptoms. The patient’s mother reported that they had been prescribed and used Triamcinolone 0.1% ointment on the affected areas twice daily for one month, but there was no improvement in her condition. In terms of her medical history, the patient has none of significance. She is currently not taking any medications, and her family history is non-contributory. Socially, she lives at home with her parents, attends elementary school, and denies the use of alcohol, tobacco, or illicit drugs. There has been no recent travel, and she has no surgical history. Additionally, the patient has no known drug allergies (NKDA).
PHYSICAL EXAM:
Patient is a well-nourished, well-appearing female who presented in no acute distress. She had a diffuse eruption of scattered hypopigmented macules without other surface changes ranging in size from 2mm – 12mm throughout her face and body. There was no oral involvement.
LABORATORY TESTS: N/A
DERMATOHISTOPATHOLOGY:
A shave biopsy was performed on the left upper back that demonstrated mild psoriasiform hyperplasia of the epidermis with a paucicellular atypical epidermotropic lymphoid infiltrate. Rare foci demonstrating “lining up” of atypical lymphoid cells along the dermoepidermal junction and haphazardly infiltrating the epidermis. In addition, there is superficial perivascular lymphohistiocytic inflammatory infiltrate with abundant incontinent melanin pigment. PAS stain is negative for fungal organisms.
Immunologic staining performed reveals a predominance of CD3+ T-cells in the atypical lymphoid cells. The CD8:CD4 ratio appears markedly increased, although the total number of atypical cells is small. There is some loss of staining with pan T-cell marker CD7. There is retention of staining with pan T-cell marker CD5. Both CD20 and CD30 immunostains highlight rare lymphoid cells. Mart-1 demonstrates a normal distribution and number of melanocytes arguing against vitiligo and most cases of pityriasis alba.
DIFFERENTIAL DIAGNOSIS:
1. Tinea versicolor
2. Leprosy
3. Hypopigmented mycosis fungoides
4. Syphilis
5. Pityriasis Alba
