What is the treatment for a small white patch on the face of a 3-year-old?

Treatment of Small White Patch on Face of a 3-Year-Old

The most likely diagnosis is vitiligo, and first-line treatment should be a potent topical corticosteroid applied for no more than 2 months, or alternatively topical tacrolimus 0.1% or pimecrolimus, which have better safety profiles for facial use in young children. 1

Diagnostic Considerations

The differential diagnosis for a small white patch on a child's face includes:

• Vitiligo - most common depigmentation disorder in children, typically presents with well-demarcated white patches 1
• Pityriasis alba - common in children, presents as hypopigmented patches with fine scale
• Tinea versicolor - fungal infection causing hypopigmented patches
• Post-inflammatory hypopigmentation - following trauma or dermatitis

Wood's light examination can help confirm the diagnosis and monitor treatment response. 1

Treatment Algorithm for Vitiligo in Young Children

First-Line Topical Therapy

For children under 18 years with facial vitiligo, initiate treatment with a potent (not ultra-high potency) topical corticosteroid for a trial period of no more than 2 months. 1 This approach balances efficacy with the risk of skin atrophy, which is a common side-effect. 1

Critical safety consideration: In children ages 0-6 years, there is increased vulnerability to HPA axis suppression due to high body surface area-to-volume ratio. 2 Therefore:

• Use limited quantities with clear application instructions 2
• Monitor closely for adverse effects 2
• Never exceed 2 months of continuous use 1

Alternative First-Line Options with Better Safety Profile

Topical calcineurin inhibitors (tacrolimus 0.1% or pimecrolimus) should be strongly considered as alternatives to potent topical steroids for facial vitiligo in children due to their superior short-term safety profile. 1

The evidence supporting this approach includes:

• Tacrolimus 0.1% achieved complete clearance of facial psoriasis within 72 hours in pediatric cases 1
• A retrospective review of 12 children with facial lesions showed clearance within 2 weeks using tacrolimus 0.1% 1
• These agents avoid the risk of skin atrophy associated with corticosteroids 1

Application Guidelines

For topical corticosteroids on the face:

• Apply once to twice daily 3
• Use low to medium potency formulations in children 0-6 years 3
• Never use ultra-high-potency corticosteroids on the face due to high risk of skin atrophy 3

For topical calcineurin inhibitors:

• Apply to affected areas as directed, typically twice daily 1
• Common side effects include burning and stinging at application site, which typically improve with continued use 1

Monitoring and Follow-Up

Serial photographs should be used to record progress at follow-up visits every 6-12 months. 1 This allows objective assessment of treatment response and disease progression.

If no response after 2 months of potent topical steroid use, or if the condition worsens, consider:

• Switching to topical calcineurin inhibitors if not already tried 1
• Referral to pediatric dermatology for consideration of phototherapy (though this is typically reserved for widespread disease or significant quality of life impact) 1

Important Caveats

Avoid abrupt discontinuation of high-potency corticosteroids without transitioning to alternative treatment, as this can cause rebound flare. 2

Rotational therapy alternating between topical vitamin D analogs, topical calcineurin inhibitors, and emollients can serve as a steroid-sparing approach if longer-term treatment is needed. 2

For a 3-year-old with a small facial patch, phototherapy is NOT recommended as first-line treatment - it should only be considered if conservative topical treatments fail and there is significant quality of life impact. 1