John was a 14-year-old entering high school this September as a freshman. He planned to go out for cross-country, and as a result had been working out with the team this past summer. His workouts consisted of running five-to-seven miles a day, with the team meeting in the middle of the afternoon. He was also a surfer and spent as much time as he could at the beach, resulting in a pretty good tan. When running he usually took his shirt off so that he could work on that tan.
Mom made an appointment because she noticed white splotches on his shoulders and back. They were not well defined; that is to say, they did not have sharply defined borders but were quite obvious. They were oval-to-round in shape and varied in size ranging from an inch to a few inches in diameter. There were ten-to-twenty splotches on his back. These areas of skin looked as if devoid of any pigment but yet were completely normal. There was no scaling, flaking or peeling, nor did it itch or bother him at all. Mom was the one who noticed them and brought it to his attention.
John seemed unimpressed by the whole matter, but mom was quite concerned. “At first I thought it might be ringworm,” she said. “But he got more of them and it didn’t seem likely that ringworm would develop like this.” She went on, “I did some reading online and really got worried when reading about vitiligo. Could this be vitiligo? After he started running for cross-country I made the appointment because it really took a turn for the worse.”
After examining John’s back we found the distribution of the lesions to be quite unique. They were on his shoulders, shoulder blades and upper back. The skin was perfectly normal with the exception that it seemed to lack pigment and was noticeably whiter than the surrounding tanned skin. I commented to mom that he looked like a doe or a fawn. His mom laughed and added, “Some of his teammates nicknamed him Bambi because of these spots.”
John had tinea versicolor, a yeast infection of the skin caused by a specific yeast called Malassezia furfur. M. furfur is part of our normal skin flora and is prevalent in areas that are rich in sebaceous or sweat glands. This condition is not uncommon in adolescents and adults.
Predisposing factors include a warm, moist environment, excessive sweating, high cortisol levels and genetics. I made the diagnosis by examining the skin with a Woods lamp (ultra violet light) which caused the areas to light up in a yellowish-gold fluorescence. I explained to John and his mom that this was a common and benign condition. By running in the heat, and sweating profusely, his skin was a perfect environment for the yeast to take over. Since he was exposing himself to the sun so regularly, the unaffected skin was tanning darker and darker. But the involved areas were not able to tan. This made it seem as if the lesions were getting worse.
John was assured that this was easy to treat, and was prescribed an anti-fungal cream to be applied twice a day for two weeks. I warned him, however, that this particular yeast was part of the normal flora and could not be eradicated. This is a condition that could return if the environment was right. Mom called me over a week later to say that his skin looked great.
Pam is a six-year-old member of a local swim club. Since summer began she has been swimming every morning from 9:00 a.m. to 10:30 a.m. Since the pool is outdoors her blond hair has taken on a greenish sheen and her skin has tanned a golden brown.
Mom made an appointment when she noticed an oval patch on Pam's left cheek that measured 1 1/2 by 2 inches. "I thought for sure that she had ringworm," Mom said in an experienced voice. "I have three sons, and I think that they've all had ringworm at one time or another. I used the same anti-fungal ointment that cleared up her brother's ringworm, but it hasn't made a difference. I've applied it religiously twice a day for almost ten days now. It just seems to have gotten worse!"
The striking thing about Pam's face was how out of place this patch seemed. Her skin was a healthy tan, but this oval patch in the lower part of her jaw was just there. It had no particular sharp border, nor an expanding border that you often see with ringworm. Upon close inspection the skin seemed to be perfectly normal. The exception was a suggestion of some flakiness in the center that was very subtle. The area did not itch or bother her in any way.
It would be easy to confuse this for ringworm, or one might assume that it was tinea versicolor as was described in the case above. The testing in the office confirmed that this was NOT a fungal infection, which cinched the diagnosis.
Pam had Pityriasis alba. This is a common skin condition that affects primarily children. These hypopigmented lesions usually occur on the face, neck, upper trunk or upper arms. The exact cause is not known, but it seems to be exacerbated by dryness. The dermatologists feel that this represents a form of eczema. It is a self-resolving lesion that causes no problems other than cosmetic concerns. It usually goes away without any treatment within several weeks to a few months. If the lesion does cause some itching it is easily remedied with a mild topical steroid. As in the case of John, Pam's rash was undoubtedly there for longer than she realized. By being out in the sun and becoming so tan the hypopigmented area stood out and seemed to worsen. Reassured that this was a totally benign condition, with the aid of dermatology books, Pam's mom elected to do nothing. Within a month Pam's normal pigmentation returned and the area tanned along with the surrounding area.