Practice Practice Pointer

An approach to hypopigmentation

BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.i6534 (Published 12 January 2017) Cite this as: BMJ 2017;356:i6534
  1. Jeremy P Hill, general practitioner with special interest in dermatology1,
  2. Jonathan M Batchelor, consultant dermatologist2
  1. 1Whyburn Medical Practice, Hucknall, Nottingham UK
  2. 2Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
  1. Correspondence to: J P Hill jeremy.hill{at}gp-c84124.nhs.uk

What you need to know

  • In many cases, non-specialists can form a working diagnosis for hypopigmentation from the history and examination alone

  • Common causes include vitiligo, post-inflammatory hypopigmentation, pityriasis versicolor, pityriasis alba, and halo naevi

  • Take time to understand how skin changes affect confidence as well as work and home life

Around 1 in 20 people have at least one hypopigmented macule.1 Patients may worry about pale patches and links to other disease. Hypopigmentation can be upsetting, particularly if visible. For people with darker skin, hypopigmentation may also result in stigma.2 Most causes of hypopigmentation are not serious, can be diagnosed clinically and may be treatable. This article aims to help non-specialists assess and treat patients with hypopigmented patches, focusing on the commonest conditions and mentioning rarer but important conditions where specialist referral may be necessary.

What features in the history and examination should I focus on?

Consider demographics:

  • Age—Pityriasis alba typically affects children, pityriasis versicolor usually affects young adults, vitiligo affects people of any age but commonly starts before the age of 30 years.

  • Race—Hypopigmented patches occur in all racial groups but are much more noticeable in those with darker skin; post-inflammatory hypopigmentation (occurring after a rash has resolved) is also more common in people with darker skin. Leprosy should be considered in patients from areas of the world where it is still prevalent.

Ask the patient to describe how the pale patch began, how it has developed and whether there are any other patches. Discuss the impact that the condition is having on the patient’s self confidence and on wider aspects of …

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