What is the management for a child with hypopigmented patches on the cheek and leg accompanied by itching?

Management of Hypopigmented Patches with Itching in Children

The most critical first step is to establish the correct diagnosis, as hypopigmented patches with itching in children most commonly represent pityriasis alba or tinea versicolor rather than vitiligo, which typically does not itch. 1, 2

Diagnostic Approach

Initial Clinical Assessment

The diagnosis can often be made in primary care based on clinical presentation 3:

• Pityriasis alba presents as ill-defined, scaly hypopigmented patches, most commonly on the cheeks of children with atopic diathesis, and is associated with itching 1
• Tinea versicolor favors the upper trunk in adolescents with associated scale; potassium hydroxide (KOH) examination reveals hyphal and yeast forms 1, 2
• Vitiligo shows complete pigment loss with periorificial distribution and typically does NOT present with itching 1

Key Distinguishing Features

• Wood's light examination can help differentiate conditions, particularly in fair-skinned patients 3, 4
• Serial photographs should document the extent and monitor changes over time 3, 4
• KOH preparation is essential if tinea versicolor is suspected 1
• Refer to dermatology if the presentation is atypical or diagnosis uncertain 3

Treatment Based on Diagnosis

For Pityriasis Alba (Most Likely Given Itching)

Topical corticosteroids are the primary treatment:

• Mid-potency topical corticosteroids (such as hydrocortisone) applied to affected areas 3-4 times daily for children 2 years and older 5
• Bland emollients (creams or ointments with minimal fragrances) should be applied regularly to address xerosis and reduce itching 3
• The condition often improves with treatment of underlying atopic dermatitis 1, 2

For Tinea Versicolor

• Antifungal therapy is curative once diagnosis is confirmed by KOH examination 1
• Proper cleaning of combs and brushes prevents reinfection 4
• Hypopigmentation may persist temporarily even after successful treatment 2

If Vitiligo is Confirmed (Less Likely with Itching)

For children under 18 years with vitiligo, topical calcineurin inhibitors are preferred over potent steroids for safety:

• Topical pimecrolimus or tacrolimus should be considered as first-line alternatives to highly potent topical steroids due to their better short-term safety profile 3
• If topical steroids are used, limit potent or very potent topical steroids to no more than 2 months due to risk of skin atrophy 3
• Narrowband UVB phototherapy is reserved for widespread disease or significant quality of life impact, monitored with serial photographs every 2-3 months 3
• Thyroid function tests should be obtained as autoimmune thyroid disease is common in pediatric vitiligo 6

Important Caveats

• Itching is uncommon in vitiligo and should prompt consideration of alternative diagnoses like pityriasis alba, tinea versicolor, or eczematous changes 1, 2
• Avoid oral corticosteroids (such as dexamethasone) due to unacceptable risk of side-effects in children 3
• Psychological assessment and support should be offered to children and parents, as pigmentation disorders can significantly impact quality of life 3
• For children with skin types I-II and limited disease, camouflage cosmetics and sunscreens may be appropriate initial management without active treatment 3