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ORIGINAL ARTICLE
Year : 2020  |  Volume : 21  |  Issue : 3  |  Page : 174-177

A study on clinical spectrum of pigmentary alterations among the pediatric population


1 Department of Medicine, GMC, Jammu, Jammu and Kashmir, India
2 Department of Dermatology, GMC, Rajouri, Jammu and Kashmir, India

Date of Submission23-Jan-2019
Date of Decision11-Feb-2019
Date of Acceptance26-Apr-2020
Date of Web Publication30-Jun-2020

Correspondence Address:
Dr. Rohini Sharma
H No. 396, Shastri Nagar, Jammu - 180 004, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpd.IJPD_1_19

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  Abstract 


Background: Human skin color is the result of a complex interplay of various intrinsic and extrinsic factors and has great heterogeneity across the globe. It also carries an esthetic value with it, and any deviation from the normal may bear immense psychological and social implications, especially among the pediatric population where it can even be a sign of systemic diseases. Aim: The aim was to study clinical and epidemiological patterns of hyper and hypo/depigmentary disorders among children. Materials and Methods: This was a prospective study where 250 individuals ≤18 years were taken up for the study. A detailed history and clinical examination was done, and relevant investigations were carried out. The data were statistically analyzed and inferences were drawn. Results: The females outnumbered the males with 136 females and 114 males. The youngest age noted was 3 months and the oldest was 17 years. There were 118 cases of hyperpigmentary disorders, and the rest 132 patients presented with hypopigmentary and depigmented disorders. The most common hyperpigmentary disorders seen were postinflammatory hyperpigmentation, periorbital melanoses, pigmentary mosaicism, and café au lait macules. Among the hypo/depigmentary disorders, most common were pityriasis alba (39, 29.5%), followed by vitiligo seen in (35, 26.5%) and postinflammatory hypopigmentation (30, 22.7%). Conclusion: This study helped us in giving a detailed insight regarding the pigmentary alterations among the pediatric population in this area, thus aiding in prompt diagnosis among various differentials. Various aggravating and predisposing factors were also noted down which could be helpful in the prevention of some of these conditions.

Keywords: Hyperpigmentation, hypo/depigmentation, pediatric, skin color


How to cite this article:
Abrol S, Sharma R. A study on clinical spectrum of pigmentary alterations among the pediatric population. Indian J Paediatr Dermatol 2020;21:174-7

How to cite this URL:
Abrol S, Sharma R. A study on clinical spectrum of pigmentary alterations among the pediatric population. Indian J Paediatr Dermatol [serial online] 2020 [cited 2020 Aug 7];21:174-7. Available from: http://www.ijpd.in/text.asp?2020/21/3/174/288478




  Introduction Top


In India, a great heterogeneity and variability does exist in terms of skin tone, and human skin is very much under the influence of multiple genes. Melanin is the primary chromophore responsible for skin color, and a series of enzymatic-driven steps collectively called as melanogenesis result in its formation. Various studies have reported differences and polymorphisms in several of these genes resulting into great diversities in the skin color.[1],[2],[3] Melanogenesis occurs in melanosomes within the melanocytes which are localized to the basal layer of the epidermis, and after formation, the melanosomes transfer melanin to keratinocytes. Besides the constitutive pigmentation influenced by the genetic makeup, a number of external and internal factors are also responsible for determining the skin color. These include endocrine, paracrine, and autocrine factors; ultraviolet rays; and even Vitamin D. Furthermore drugs, topical chemical substances, and heavy metals can too alter the skin color. Any disorder of pigmentation, either genetic or acquired, may either involve defect in migration of melanocytes from the neural crest, melanogenesis, transfer of melanosomes from melanocytes to keratinocytes, destruction of melanocytes, or impaired degradation of melanocytes.[4],[5] The pigmentary disorders are commonly encountered among the pediatric age group which includes anybody who is ≤18 years and carries immense social or psychological implications. They can even be a sign of some systemic diseases. There is paucity of studies in the literature about various pigmentary alterations involving both hypopigmentation and hyperpigmentation among children. In this study, pigmentary disorders including hyperpigmentation, hypopigmentation, depigmentation, and others are thus studied among the pediatric age group.


  Materials and Methods Top


This was a prospective study carried out over a period of 3 months at a tertiary care center of North India. A total of 250 children attending the outpatient department between the age group of 0 and 18 years presenting with any type of pigmentary disorders were taken up for the study after obtaining approval from the ethical committee. An informed consent was obtained from all the parents and guardians. The children were divided into two categories as either suffering from hyperpigmentary or hypopigmentary disorder and accordingly categorized into two. Further, under each category, age group-wise distribution was done which included<28 days,<1 year, 1–5 years, 6–11 years, and 12–17 years. Patients and guardians who did not give any consent were excluded from the study. A detailed clinical history regarding age, duration, familial history, and other associated skin or systemic disease present was noted. All predisposing and aggravating factors such as sunlight, use of chemical substances, drug intake, and hormonal disturbances were also noted. A detailed clinical examination was done to see for the site, size morphology, pattern, and distribution was recorded. All these findings were recorded in a preformed pro forma. Statistical test used was Chi-square test. The data were subjected to descriptive analyses using the Observed data were subjected to descriptive analysis using SPSS software, version 22.0, Chicago, USA. Ethical Clearance was taken from the institute.


  Results Top


A total of 250 children aged below 18 years, with various types of pigmentary alterations, were taken up for the study. Females outnumbered the males with 136 (54.4%) females and 114 (45.6%) males. The youngest age noted was 3 months, and the oldest was 17 years. There were 118 (47.2%) cases of hyperpigmentary disorders, and the rest 132 (52.8%) patients presented with hypopigmentary and depigmented disorders.

Among the hyperpigmentary disorders, most common was postinflammatory hyperpigmentation [Figure 1] seen in 39 (24.5%) patients. This was followed by periorbital/oral melanosis in 18 (15.2%) patients, pigmentary mosaicism was seen in 12 (10.1%) patients, café au lait macules (CALMs) in 9 (7.6%) patients, Mongolian spot [Figure 2] in 9 (7.6%) patients, lentigines in 7 (6%) patients, lichen planus in 6 (5%) patients, and acanthosis nigricans in 6 (5%) patients. Among the predisposing/aggravating factors, sunlight was seen in 48 (40.6%) children. The use of chemicals was seen in 10 (8.4%) children, and all of these presented with postinflammatory hyperpigmentation. Hormonal abnormalities were seen in six patients of acanthosis nigricans. Family history of similar complaints was seen in 10 (8.4%) patients of periorbital melanosis and 4 (3.3%) patients of lentigines. The distribution of various types of hyperpigmentation is shown in [Table 1].
Figure 1: Postinflammatory hyperpigmentation after Fixed drug eruption (FDE)

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Figure 2: Mongolian spot

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Table 1: Types of hyperpigmentation among the pediatric age group

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The most common site of involvement was the face seen in 51 (43.2%) patients, followed by the chest in 23 (19.4%) patients, the back in 18 (15.2%) patients, the lower limbs in 15 (12.7%) patients, and finally, the upper limb and the stomach in 11 (9.3%) patients. The most common age group seen was 12–17 years (46, 38.9%), followed by 1–5 years (31, 26.2%), 6–11 years (18, 15.2%),<1 year (16, 14.2%), and finally,<28 days (7, 5.9%). Systemic involvement was seen in two patients of CALM who had features of neurofibromatosis. In two patients of acanthosis nigricans, features of polycystic ovarian syndrome were seen.

Among the hypopigmented/depigmented disorders, maximum patients were of pityriasis alba (39, 29.5%), followed by vitiligo [Figure 3] (35, (26.5%) and postinflammatory hypopigmentation (30, 22.7%). Among 35 vitiligo patients, 29 were of nonsegmental vitiligo and the rest were segmental. Family history of similar complaints was present in 20 (15.1%) patients of vitiligo, 5 (4%) patients of leprosy, and 2 (1.5%) patients of oculocutaneous albinism. Sunlight was the predisposing factor in 20 (15.1%) patients of pityriasis alba. The distribution of various types of hypopigmentation is shown in [Table 2]. The most common site of involvement was the face in 61 (46.2%) patients, followed by back in 26 (19.6%) patients, chest in 19 (14.3%) patients, upper limb in 12 (9%) patients, lower limb in 9 (6.8%) patients, and finally, abdominal involvement was seen in 7 (5.3%) of the patients. The most common age group involved was 6–11 years with 61 (46.2%) patients, followed by 12–17 years (48, 36.3%). There were 15 (11.3%) patients<1 year and finally, 8 (6%) patients in 1–5 years of age group. Systemic involvement was seen in two patients of ash leaf macules who had features of tuberous sclerosis complex.
Figure 3: Vitiligo

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Table 2: Types of hypopigmentation/depigmentation among pediatric patients

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  Discussion Top


A wide spectrum of pigmentary alterations is commonly encountered among the pediatric population. It can be seen either immediately after birth or at any time in life. They carry immense psychological as well as social implications more so owing to the growing and sensitive phase of life in the pediatric spectrum. In our study, a myriad of pigmentary alterations were seen encompassing hypopigmentation, hyperpigmentation, and depigmentation. Females outnumbered the males in our study, whereas few other studies have reported a male preponderance. This could be due to an increased sense of concern among parents of the girl child.

Among the hyperpigmentary disorders, postinflammatory hyperpigmentation was the main finding seen in 39 (24.5%) patients. This was a higher percentage compared to other studies, and this can be attributed to a greater proportion of people belonging to the darker skin type. Various studies reported the same findings of increased patients with postinflammatory hyperpigmentation among darker skin types.[6],[7] The release of various cytokines, chemokines, and prostanoids after an inflammatory event, thereby stimulating the melanocytes, has been proposed as the possible mechanism.[8] Periorbital melanosis was seen in 18 (15.2%) patients, pigmentary mosaicism in 12 (10.1%) of the patients, and CALM in 9 (7.6%) patients. Another study reported CALM to be the most common at 20.6%, followed by postinflammatory hyperpigmentation (15.5%).[6] This could be due to the difference in ethnic and regional variations and difference in the age group considered. In our study, CALM was associated with neurofibromatosis in two patients. Another study reported similar findings of CALM seen in 25% and its association with neurofibromatosis in two patients.[9] The proportion of pigmentary mosaicism in the same study was in concordance with our study. Other hyperpigmentary disorders in the form of Mongolian spot, lentigines, lichen planus, acanthosis nigricans, urticaria pigmentosa, fixed drug eruptions, pityriasis versicolor, and lichen striatus demonstrated similar patterns. In our study, the face was most commonly involved, followed by the chest and back, which was discordant with another study in which the chest and lower limbs were most commonly involved. The difference could be attributed to the age group selected and the pattern of hyperpigmentation seen.[6]

Among the hypopigmentary disorders, pityriasis alba was seen in majority at 29.5%, which was well in accordance to various other studies who reported similar findings.[10],[11] Pityriasis alba is associated with itching sometimes and occurs majorly below the age of 14 years. Vitiligo was seen in 26.5% of the patients, followed by postinflammatory hypopigmentation in 22.7% of the patients. Leprosy too was seen in 5.3% of the patients. Another study from South India reported a higher percentage of vitiligo at 47% which could be due to regional and genetic variations. As far as leprosy was concerned, one study reported it in 4.5% well in accordance to ours.[12] Leprosy in children carries significance as it aids in knowing the disease transmissibility. However, postinflammatory hypopigmentation had a higher proportion of patients. Postinflammatory hypopigmentation following any inflammatory episode is due to an acquired defect in the transfer of melanin to keratinocytes and has great variability depending upon variable sensitivity of population.[13] Other hypopigmentary lesions seen were nevus depigmentosus, nevus anemicus, halo nevus, hypomelanosis of Ito, oculocutaneous albinism, ash leaf macules, piebaldism, and morphea. Nevus anemicus is a hypopigmentary disorder without pigment loss and is the result of aberrant hypersensitive response to catecholamines.[14] These were more commonly seen in our study than others, and all of these were seen in children<5 years. Nevus depigmentosus followed blaschkoid pattern and along with hypomelanosis of Ito is the result of pigmentary mosaicism as per the theory of Happle which clubs all hypopigmented and depigmented macules in blaschkoid pattern consequent to mosaicism.[15] Regarding the site of involvement, the face was most commonly involved, followed by the chest, back, limbs, and finally abdomen, and this is mostly governed according to the pattern of disorders seen. Both patients of ash leaf macules were having tuberous sclerosis with other cutaneous and systemic involvement as well in the form of Shagreen patch, angiofibromas, periungual fibroma, and hamartomas.[16]


  Conclusion Top


This study was helpful in giving us a detailed insight of the spectrum of pigmentary alterations among the pediatric population of the northernmost part of India. A wide range of pigmentary alterations were seen including both hyperpigmentation hypopigmentation, and depigmentation. Various aggravating factors and predisposing factors were also noted which could be helpful in preventing these conditions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Shriver MD, Parra EJ, Dios S, Bonilla C, Norton H, Jovel C, et al. Skin pigmentation, biogeographical ancestry and admixture mapping. Hum Genet 2003;112:387-99.  Back to cited text no. 1
    
2.
Stokowski RP, Pant PV, Dadd T, Fereday A, Hinds DA, Jarman C, et al. A genome wide association study of skin pigmentation in a South Asian population. Am J Hum Genet 2007;81:1119-32.  Back to cited text no. 2
    
3.
Mukherjee M, Mukerjee S, Sarkar-Roy N, Ghosh T, Kalpana D, Sharma AK. Polymorphisms of four pigmentation genes (SLC45A2, SLC24A5, MC1R and TYRP1) among eleven endogamous populations of India. J Genet 2013;92:135-9.  Back to cited text no. 3
    
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Seiberg M. Keratinocyte-melanocyte interactions during melanosome transfer. Pigment Cell Res 2001;14:236-42.  Back to cited text no. 4
    
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Dogra S, Sarangal R. Pigmentary disorders: An insight. Pigment Int 2014;1:5-7.  Back to cited text no. 5
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Sori T, Jaisankar TJ, Thappa DM, Nath AK. Hyperpigmentary disorders in children: A hospital-based study in a tertiary care center. Indian Dermatol Online J 2013;4:148-52.  Back to cited text no. 6
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7.
Taylor SC, Grimes PE, Lim J, Im S, Lui H. Postinflammatory hyperpigmentation. J Cutan Med Surg 2009;13:183-91.  Back to cited text no. 7
    
8.
Davis EC, Callender VD. Postinflammatory hyperpigmentation: A review of the epidemiology, clinical features, and treatment options in skin of color. J Clin Aesthet Dermatol 2010;3:20-31.  Back to cited text no. 8
    
9.
McLean DI, Gallagher RP. “Sunburn” freckles, café-au-lait macules, and other pigmented lesions of schoolchildren: The Vancouver mole study. J Am Acad Dermatol 1995;32:565-70.  Back to cited text no. 9
    
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Pinto FJ, Bolognia JL. Disorders of hypopigmentation in children. Pediatr Clin North Am 1991;38:991-1017.  Back to cited text no. 10
    
11.
Vinod S, Singh G, Dash K, Grover S. Clinico epidemiological study of pityriasis alba. Indian J Dermatol Venereol Leprol 2002;68:338-40.  Back to cited text no. 11
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Kumar B, Rani R, Kaur I. Childhood leprosy in Chandigarh: Clinicohistopathological correlation. Int J Leprol 2000;68:330-1.  Back to cited text no. 12
    
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van Geel N, Speeckaert M, Chevolet I, de Schepper S, Lapeere H, Boone B, et al. Hypomelanoses in children. J Cutan Aesthet Surg 2013;6:65-72.  Back to cited text no. 13
    
14.
Ahkami RN, Schwartz RA. Nevus anemicus. Dermatology 1999;198:327-9.  Back to cited text no. 14
    
15.
Happle R. Mosaicism in human skin. Understanding the patterns and mechanisms. Arch Dermatol 1993;129:1460-70.  Back to cited text no. 15
    
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Kohrman MH. Emerging treatments in the management of tuberous sclerosis complex. Pediatr Neurol 2012;46:267-75.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

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