Study of Hypopigmented patches children attending to the Dermatology clinic in a 3ry care hospital of Sri Lanka
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Study of Hypopigmented patches children attending to the Dermatology clinic in a 3ry care hospital of Sri Lanka
- 1. A STUDY OF HYPOPIGMENTED SKIN LESIONS PRESENTING TO AN OUTPATIENT SKIN CLINIC IN A TERTIARY CARE HOSPITAL FOR CHILDREN M.K.D. Tissera J.K.K. Senivirathne B.D.W. Jayamanne
- 2. Introduction • Skin colour is important • Visible socio-cultural characteristic of an individual • Any deviation of normal pattern is significant • Normal skin colour composed of 4 biochromes – – – – Brown – from Melanin Blue - Reduced Hemoglobin Red - Oxyhaemoglobin Yellow- Exogenous –eg :Diet ( carotinoids ) • The major skin colour determinant is Melanin
- 3. Background • Hypopigmentation or depigmentation, particularly in skin type 4 to 5 can have a profound psychological impact • Diagnosing hypopigmented skin lesions in paediatric practice is challenging • Could be due to genetic or acquired – Acquired are common • Hypopigmented facial lesions often cause distress to parents
- 4. Objectives To determine, 1. The prevalence of hypopigmented skin lesions among the children who present to the clinic 2. The percentage of patients who could be diagnosed by clinical examination alone 3. The percentage of patients requiring additional procedures for the diagnosis (Ex: Scrapings, Wood’s light examination, skin biopsy) 4. The percentage of patients having generalized skin disorders in addition to the facial lesions.
- 5. Methods • Descriptive cross sectional study • Study setting : Dermatology clinic of Lady Ridgeway Hospital(LRH) for Children Colombo, Sri Lanka.
- 6. Lady Ridgeway Hospital –Sri Lanka •National referral centre for Paediatric care •Over 700 beds •Around 30 different services with16 specialties • Located in Colombo http://www.ladyridgewayhospital.lk
- 7. Methods… • Study period: 06 months(01st April to 30th Sep. 2011) • Total of 1000 children (boys and girls) • Data Collection – All children (aged below 14yrs) had a complete clinical evaluation. – Diagnosis of hypopigmented lesions were done according to current clinical criteria – Demographic data & relevant investigations and demographic data were gathered
- 8. Methods… – The facial lesions were photographed with informed written consent of the parents/guardian – Exclusion criteria: Children with systemic diseases who had secondary hypopigmentation – Data Analysis: Data were analyzed by SPSS (v.18)
- 9. Methods… • Ethical considerations : Ethical clearance was obtained from the Ethical Review Committee of LRH, Colombo. • A brief verbal introduction of the study was provided to each patient and their parents/guardians by the investigator and they were invited to participate in the study.
- 10. Results • Total study population was 15,000. • Out of them 1000 (6.4%) were included in the study. • Mean age of the study group was 4.9y (± 3.7 SD) and 29% were above 7y. • 52 % were girls.
- 11. Results… Facial Lesions Upper Limbs Trunck Lower limbs All other 12% Facial only 68% 13% 32% 39% Facial + other sites 36% Skin Scrapings All the other Clinical Diagnosis Clinical only 81% 19% Clinical + Ix 61% 39% Wood’s lamp ,biopsy, IgE levels
- 12. Results… • Majority were immune/auto immune related conditions (46%)
- 13. Results… Condition Atopic Dermatitis Pityriasis Versicolor Photodermatitis Leprosy Post inflammatory Hypopigmentation Pityriasis Alba Vitiligo Pigmentory Mosaicism Pityriasis Lichenoides Chronica Lichen Striatus Tuberous Sclerosis Others % 28.2 23.2 11.7 7.9 6.3 6.2 6.0 2.9 2.0 1.8 1.2 2.6
- 14. Results… Immune /Auto-Immune (46%) Diagnosis % Overall % Atopic Dermatitis Pityriasis Alba * 62.2 13.6 28.2 6.2 Vitiligo Pityriasis Lichenoides Chronica Lichnen Striatus 13.2 4.4 3.5 6.0 2.0 1.8 Actinic Lichen Planus Pityriasis Rosea 2.0 1.1 0.9 0.5
- 15. Infective (31.7%) Diagnosis Results… % Overall % Pityriasis Versicolor 73.0 23.2 Leprosy 24.8 7.9 Tinea faciei 2.2 0.7 % Overall % 75.2 24.8 11.7 6.3 % Overall % 70.7 29.3 2.9 1.2 Inflammation (18%) Diagnosis Photodermatitis* Post inflammatory Congenital (4.1%) Diagnosis Pigmentary Mosaicissm Tuberous Sclerosis
- 18. Atopic Dermatitis with trunk lesions ©LRH,LK
- 24. Vitiligo ©LRH,LK
- 25. Vitiligo ©LRH,LK
- 26. Leprosy ©LRH,LK
- 27. Leprosy ©LRH,LK
- 29. Results… • Mean ages of presentation Condition Mean (yrs) SD(yrs) Congenital Immune /Auto-Immune Infective 3.7 4.3 5.0 3.2 3.4 4.1 Inflammatory 6.7 3.2 • Significant different was seen between mean ages of presentation (p <0.001) • Further analysis revealed that there is no significant mean differences with congenital from Immune and Infective aetiologies
- 30. Results… Clinical Dx % Infective Immune related 58 % 88% Inflammatory 100% Congenital 100%
- 31. Results… Immune / Auto-Immune Diagnosis Atopic Dermatitis Pityriasis Alba Vitiligo Pityriasis Lichenoides Chronica Licnen Striatus Actinic Lichen Planus Pityriasis Rosea Clinical Dx (%) 84.5 94.4 98.3 50.0 94.4 100.0 100.0 • Actinic Lichen Planus and Pityriasis Rosea were diagnosed only clinically
- 32. Results… • Among 69.1% of remaining immune conditions were diagnosed by performing IgE levels and 20% by biopsies • Infective Diagnosis Pityriasis Versicolor Leprosy Tinea faciei Clinical Dx(%) 59.5 59.9 0.0 • Among rest of the infective conditions , 83% were diagnosed by performing skin scraping microscopy and 11.6% by biopsies •All Taenia faciei were diagnosed by skin scrapings
- 33. Conclusions • Most of hypopigmented skin lesions can be diagnosed clinically. • Commonest hypopigmented skin lesions were related to atopic dermatitis. • 2nd, 3rd -Pityriasis versicolor, photodermatitis . • Most common anatomical sites were face, upper limbs and trunk. • No significant sex different was found with respect to aetiology (p =0.299). • Significant difference was found between mean age of presentation and aetiology (p<0.001)
- 34. References • Brenninkmeijer EE, Spuls PI, Legierse CM, et al. (2008) Clinical differences between atopic and atopiform dermatitis. J Am Acad Dermatol 58: 407-414. • Jena DK, Sengupta S, Dwari BC, et al. (2005) Pityriasis versicolor in the pediatric age group. Indian J Dermatol Venereol Leprol 71: 259-261. • Lapidus CS and Honig PJ. (1994) Atopic dermatitis. Pediatr Rev 15: 327-332. • Pinto FJ and Bolognia JL. (1991) Disorders of hypopigmentation in children. Pediatr Clin North Am 38: 991-1017.
- 35. References… • Sori T, Nath AK, Thappa DM, et al. (2011) Hypopigmentary disorders in children in South India. Indian J Dermatol 56: 546-549. • Tay YK, Kong KH, Khoo L, et al. (2002) The prevalence and descriptive epidemiology of atopic dermatitis in Singapore school children. Br J Dermatol 146: 101-106. • Toossi P, Nabai L, Alaee Z, et al. (2007) Prevalence of skin diseases and cutaneous manifestations among Iranian children: a survey of 1417 children. Arch Dermatol 143: 115-116. • Jena DK, Sengupta S, Dwari BC, et al. (2005) Pityriasis versicolor in the pediatric age group. Indian J Dermatol Venereol Leprol 71: 259-261..
- 36. Special Thanks • Prof. J.K.K.Seneviratne, Associate Professor in Dermatology, University of Sri Jayawardanapura, Consultant Dermatologist, Lady Ridgeway Hospital for the Children (Teaching), Colombo • All the patients who participated and their parents/guardians • All the staff members in Dermatology unit LRH
- 37. Thank you Visit Sri Lanka
Editor's Notes
- Good afternoon ladies and gentlemen , I ‘m here to present “a study of hypopigmented skin lesions presenting to an outpatient skin clinic in a tertiary care hospital for children” . I’m presenting behalf of Dr.Tissera who is the principal investigator of this study currently attached to Broadgreen Hospital ,Liverpool U.K. During my presentation I would like to go through some interesting slides of actual patients also
- Skin colour is an important visible scoio-cultural characteristic for an individual.Any deviation from normal pattern is significantThe major skin color determinants is Melanin So the visible pigmentation of the skin (or hair) depends on the amount of melanin, degree of vascularity, and presence of carotene - (type of melanin (eumelanin versus pheomelanin))
- Loss of pigmentation of the facial skin, particularly in this part of the world often cause distress to the patients.Acquired causes are common according to the available literatureDiagnosing hypopigmented skin lesions in paediatric practise is challenging
- Our objectives wereTo determine the prevalence of hypopigmented skin lesions To assess the percentages of children who could be diagnosed by only clinically and who need additional procedures for the diagnosis Needed to see the proportion of generalized form of the diseases also
- MethodologyStudy was a descriptive cross sectional study which was conducted at the Dermatology clinic of Lady Ridgeway Hospital for Children in Colombo
- Let me brief you all about the Lady Ridgeway hospital, which is located in Colombo It is the National referral centre for Paediatric care with more than 30 different services,Have Over 700 beds. You can visit the website for further information
- Conducted the study for six months during 2011 from April with a convenient sample 1,000 children All children were clinically evaluatedDiagnosis done according to the current clinical criteriaRelevant investigations and demographic data were gathered by the principal investigator
- Children with systemic diseases who had secondary hypopigmentation were excluded Data were entered in to a spreadsheet and analyzed with SPSS
- Ethical clearance was obtained from the Ethical Review Committee of the hospital.A brief verbal introduction of the study was provided to each patient and their parents/guardians by the investigator and they were invited to participate in the study.
- Time to move on to the results,There were 15,000 children in the study population Out of which, 06 % had hypopigmented lesions with the mean age of 5yrs52 % were girls
- Lesions were present only on the face in 68% of children and commonest sites of other involvement were upper limbs, Trunck & lower limbs81% of them were diagnosed clinicallyCommonest diagnostic procedure was skin scrapings for microscopy and KOH examination which accounted 61% of diagnostic procedures
- Majority had immune related conditions
- This table shows the ordered list of the conditions that we came across.There you see Atopic dermatitis and related conditions seen in 28% which was the commonest type Pityriasis vesicular and photodermatitis present in double figures with ranking 2nd and 3rd respectivelyResolving PityriasisRosea was least common (0.5%)
- Let’s move on to further analysis,according to aetiologies Immune related conditions which accounted 46 % from allPityriasis Alba 2nd place and Vitiligo 3rd place
- 73% of the time its PityriasisVersicoloramong infective lesions and 75 % Photodermatitisamong inflammatory conditions PigmentaryMosaicissm was seen in 71% among congenital entities
- I’m going to show few interesting lesions Thesewere photographed with informed written consent of the parents/guardian
- An infant with Atopic Dermatitis Facial lesions
- Body lesions of the same child
- Another infant with Atopic Dermatitis
- Another Atopic Dermatitis facial lesion - elder child ,low grade eczema
- Child with facial Pityriasisversicolor- By Malasseziaspp
- Child with Photo dermatitis or sun poisoning
- Child presented with tuberous sclerosis - “ash leaf “ lesions
- Child with vitiligo
- Another child with Vitiligo
- Child with Leprosy facial lesions - Lepromatous Leprosy
- Same child’s upper limb lesion
- Pityriasis alba - self limiting condition
- Statistically significant difference seen with age of presentation among main aetiological categories that we classified
- 100 % of the time clinical diagnosis was able to made with Congenital and Inflammatory lesions 88 % were able to diagnose clinically with immune related conditions and 58 % with infective conditions
- Further,Acinic Lichen Planus and resolving PityriasisRosea were diagnosed only clinically among immune related conditions98 % out of vitiligo and 84 % of atopic dermatitis were able to diagnose clinically
- IgE levels done in 69 % of patients to diagnose remaining immune conditionsSkin scraping microscopy were performed in 83% to diagnose infective conditions All Taeniafaciei were diagnosed by skin scrapings
- In conclusions, Most of the hypopigmented skin lesions can be diagnosed clinically Commonest hypopigmented skin lesions were related to atopic dermatitis Commonest aetiology was immune relatedMost common anatomical sites were face, upper limbs and trunk.No significant sex different was found with respect to aetiology but significant difference was found between mean age of presentations
- These were our references
- Special thank goes to Prof.Senivirathne ,all the participants and staff members
- Thank you very much to all of you !