What is the diagnosis and treatment for white spots on a bald head and chin?

White Spots on Bald Head and Chin: Diagnosis and Treatment

Diagnosis

The white spots spreading on the bald head and chin are most likely vitiligo, a depigmentation disorder characterized by sharply demarcated white patches that progressively spread over time. 1

Key Diagnostic Features to Confirm Vitiligo:

• Sharply demarcated white patches with complete loss of pigmentation (not just lightening) 1
• Symmetrical distribution is typical, though asymmetric patterns can occur 2
• Progressive spreading over months to years 1
• Wood's light examination enhances visualization of depigmented areas, particularly helpful in fair-skinned individuals 3, 2
• Serial photographs should document extent and monitor progression 3, 2

Critical Differential Diagnoses to Exclude:

• Pityriasis alba: presents with hypopigmented (not completely white) patches, often with fine scale, typically in children 4
• Tinea versicolor: shows hypopigmented patches with fine scale, positive KOH preparation 4, 5
• Postinflammatory hypopigmentation: history of preceding inflammation or injury 4
• Alopecia areata with white hair regrowth: presents with hair loss patches, not skin depigmentation 1

Recommended Workup:

• Thyroid function tests including anti-thyroglobulin antibodies should be performed due to high prevalence of autoimmune thyroid disease in vitiligo patients 2
• KOH preparation if any scale present to exclude tinea versicolor 4
• Skin biopsy only if diagnosis uncertain or atypical features present 3

Treatment Algorithm

First-Line Treatment (Start Here):

For localized vitiligo on face and head, initiate potent topical corticosteroids (such as fluticasone or betamethasone) applied once daily for up to 2 months maximum. 1

• Fluticasone alone induces mean repigmentation of 9% over 9 months 1
• Betamethasone can achieve 90-100% repigmentation in approximately 26% of patients 1
• Critical caveat: Limit potent/highly potent topical steroids to maximum 2 months to avoid skin atrophy, particularly on the face 1, 6

Alternative First-Line Option:

Topical calcineurin inhibitors (tacrolimus or pimecrolimus) are preferred for facial vitiligo when prolonged treatment beyond 2 months is needed, as they avoid steroid-related skin atrophy. 3

• Pimecrolimus achieved 50-100% repigmentation in 8 of 10 patients over 8 weeks 1
• Safer for long-term facial use compared to potent steroids 3

Second-Line Treatment (If First-Line Fails):

Combination therapy: Potent topical steroid (fluticasone) plus narrowband UVB phototherapy for more extensive or refractory disease. 1

• Fluticasone + UVA induced mean repigmentation of 31% versus 9% with fluticasone alone 1
• Narrowband UVB is preferred over PUVA for superior safety profile 6
• Monitor with serial photographs every 2-3 months to document response 6

Treatments to AVOID:

• Calcipotriol (vitamin D analog) alone is NOT effective for vitiligo and should not be used as monotherapy 1
• Oral corticosteroids have unacceptable risk of side-effects and are not recommended 1, 3
• Contact immunotherapy is reserved only for extensive alopecia areata (not vitiligo) 1

For Patients with Fair Skin (Types I-II):

Consider initial management with camouflage cosmetics, fake tanning products, and sunscreens without active treatment, particularly if disease extent is limited and patient preference supports this approach. 1

Important Clinical Pitfalls:

• Do not exceed 2 months of potent topical steroid use on the face/head due to high risk of skin atrophy, particularly with clobetasol (highly potent) which caused atrophy in all users after just 8 weeks 1, 6
• Do not assume all white spots are vitiligo: Always consider tinea versicolor (especially if any scale present) and pityriasis alba in the differential 4
• Do not forget thyroid screening: Autoimmune thyroid disease is highly prevalent in vitiligo patients 2
• Do not underestimate psychological impact: Offer psychological support and counseling, as vitiligo significantly affects quality of life 1, 3, 6

Monitoring Strategy:

• Serial photographs at baseline and every 2-3 months to objectively document treatment response 3, 6, 2
• Reassess treatment efficacy at 2-3 months: If no response, switch to alternative therapy or add phototherapy 6
• Refer to dermatology if diagnosis uncertain, atypical presentation, or failure of first-line treatments 3, 2