What are the causes and treatments of small white spots on a child's face?

Small White Spots on a Child's Face

The most common causes of small white spots on a child's face are pityriasis alba (hypopigmented patches associated with atopic skin), milia (tiny keratin cysts), molluscum contagiosum (viral pearly papules), and tinea versicolor (fungal infection), with treatment directed at the specific diagnosis. 1, 2

Diagnostic Approach

Initial Clinical Assessment

Visual inspection and palpation are essential first steps, looking specifically for: 3

• Distribution pattern: Perioral/perinasal suggests perioral dermatitis; cheeks suggest pityriasis alba; scattered suggests molluscum or milia 4, 2
• Texture: Raised pearly papules with central umbilication indicate molluscum; flat smooth patches suggest pityriasis alba or vitiligo; tiny firm bumps suggest milia 1, 2
• Scale: Fine scale on hypopigmented patches suggests pityriasis alba or tinea versicolor 2
• Associated symptoms: Pruritus occurs with atopic dermatitis, pityriasis alba, and tinea versicolor 1, 2

Wood's light examination enhances visualization of hypopigmented lesions, particularly in fair-skinned children. 3

Serial photographs should document extent and monitor changes over time. 3

Common Diagnoses and Management

Pityriasis Alba (Most Common)

Pityriasis alba presents as ill-defined, scaly hypopigmented patches on the cheeks of children with atopic tendency. 2

• Apply bland emollients regularly to address xerosis and reduce itching 3
• Low-potency topical corticosteroids (hydrocortisone 1-2.5%) can be used for acute flares on the face 5, 6
• Reassure parents this condition is benign and often self-resolving 2

Milia

Milia appear as flesh-colored or white 1-2mm papules, most common in newborns but can occur in older children. 7

• Observation is appropriate as most resolve spontaneously 7
• Curettage with electrodesiccation can be performed if persistent and cosmetically concerning 7

Molluscum Contagiosum

Molluscum presents as flesh-colored or pearly white papules with characteristic central umbilication. 1

• This highly contagious viral infection usually resolves without intervention within 6-18 months 1
• Treatment options include observation, cryotherapy, or curettage if lesions are symptomatic or spreading 1, 7
• Topical imiquimod may be considered for refractory cases 7

Tinea Versicolor

Tinea versicolor favors the upper trunk but can affect the face, presenting as hypopigmented scaly patches. 2

• Diagnosis confirmed by potassium hydroxide (KOH) examination showing hyphae and yeast forms 2
• Topical antifungal therapy is first-line in children due to favorable safety profile 8
• Proper cleaning of combs and brushes prevents reinfection 8

Vitiligo

Vitiligo shows complete pigment loss in a periorificial distribution (around mouth, nose, eyes) with well-demarcated borders, distinguishing it from pityriasis alba. 2

• For children under 18 years, topical calcineurin inhibitors (tacrolimus 0.1%) are preferred over potent steroids for facial lesions 3
• If topical steroids are used, limit potent formulations to no more than 2 months due to atrophy risk 3
• Perform thyroid function tests including anti-thyroglobulin antibodies, as vitiligo associates with autoimmune thyroid disease 3

Perioral Dermatitis

Perioral dermatitis presents as flesh-colored or erythematous papules and micronodules around the mouth, nose, or eyes. 4

• Discontinue any topical fluorinated corticosteroids immediately, as these often trigger the condition 4
• Topical metronidazole is first-line treatment 4
• Oral erythromycin can be added for more severe cases (tetracycline reserved for children >8 years) 4
• Low-potency topical steroid may help wean off strong steroids and suppress inflammation 4

Referral Indications

Refer to pediatric dermatology when: 3

• Multiple hypopigmented lesions with irregular borders are present
• Diagnosis remains uncertain after initial evaluation
• Lesions show rapid growth, bleeding, pain, or nodule development
• Complete pigment loss suggests vitiligo requiring specialized management

For solitary small lesions without concerning features, referral can be delayed or managed in primary care. 3

Critical Safety Considerations

When using topical corticosteroids on children's faces: 6

• Use only low-potency agents (Class V/VI such as hydrocortisone 1-2.5%) 6
• Infants and young children (0-6 years) are particularly vulnerable to HPA axis suppression due to high body surface area-to-volume ratio 6
• Prescribe limited quantities with clear application instructions to prevent overuse 6
• Avoid abrupt discontinuation of potent steroids due to rebound flare risk 6