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Western Visayas Sanitarium
January 31, 2011
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yA.C
y9 months old/FemaleyNew Lucena
yCC: white patches on the face
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y 5 months prior to consult, mother noted white patchon the right preauricular area of the patient. Motherdidnt bother to seek consult.
y 4 months prior to consult, white patches were noted tohave increase in size. No consult done. No remediesgiven.
y 3 months prior to consult, lesions spread to the frontal
and orbital areas. No change in color of the lesions. Noconsult done and no medications given.
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y 2 months prior to consult, there was progression of thesize of the lesions involving the cheek areas. Noconsult done. No medications were given.
y Persistence of signs until the day of consult promptedthe mother to seek consult.
y Pertinent negatives: pruritus, crusting, no previous useof topical cream or ointments
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y Prenatal
y Mother started her Prenatal check-up at 4 monthsAOG at a LocalBrgy HealthCenter and regularly thereafter. No maternal illnesses
y Natal
y Born full term via NSD at the Health Center asssited by a midwifey Postnatal
y No complications after birth
y No previous hospitalizations
y Feeding
y Breastfed until present. Started supplementary feeding withformula milk at 4 months of age
y Immunization
y Completed c/o LHC
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y
No previous hospitalizationsy No food and drug allergic reactions
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y No bronchial asthma
y No allergies
y No same lesions noted within the family
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y Patient was active and playful
y VITAL SIGNSy CR: 112y RR: 36
y Temp: 36.8
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y SKINy Brown and dry
y White macular lesions diffusely distributed over the
frontal, orbital and maxillary areas
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yHEENTy Normocephalic , whitish macular lesions on the face
y Pearly white sclerae, pinkish conjuctiva
y No ear and nasal dischargesy Moist lips and buccal mucosa
y No cervical lymphadenopathies
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y CHESTy Symmetrical chest expansion
y Clear breath sounds
y Normal cardiac rate and regular rhythm
y Adynamic precordium
y No murmurs noted
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y ABDOMENy Round
y Normoactive bowel sounds
y Soft, non-tendery No masses
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y EXTREMITIESy Grossly normal
y No lesions noted
y Capillary refill time < 2 seconds
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y T/CPityriasis versicolor
D
ifferentialsy Vitiligo
y Seborrheic dermatitis
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y KOH smear
y Ketoconazole 2% cream OD x 2 weeks
y Sulfur soap wash BID
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y chronic asymptomatic scaling epidermomycosisassociated with the superficial overgrowth of thehyphal form ofMalassezia furfur, characterized by
well-demarcated scaling patches with variablepigmentation, occurring most commonly on the trunk.
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Etiologyy M. furfur(previously known as Pityrosporum ovale, P.
orbiculare) is a lipophilic yeast that normally resides in
the keratin of skin and hair follicles of individuals atpuberty and beyond. It is an opportunistic organism,causing pityriasis versicolor andMalassezia folliculitisand is implicated in the pathogenesis of seborrheic
dermatitis.Malassezia infections are not contagious;rather, overgrowth of resident cutaneous flora occursunder certain favorable conditions.
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Age ofOnsety Young adults. Less common when sebum production
is reduced or absent; tapers off during fifth and sixth
decades.
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y Malassezia changes from the blastospore form to themycelial form under the influence of predisposingfactors. Dicarboxylic acids formed by enzymatic
oxidation of fatty acids in skin surface lipids inhibittyrosinase in epidermal melanocytes and thereby leadto hypomelanosis. The enzyme is present in theorganism.
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Duration of Lesionsy Months to years.
Skin Symptomsy Usually none.Occasionally, mild pruritus. Individuals
with PV usually present because of cosmetic concernsabout the blotchy pigmentation.
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Distributiony Upper trunk, upper arms, neck, abdomen, axillae,
groins, thighs, genitalia. Facial, neck, and/or scalp
lesions occur in patients applying creams/ointments ortopical glucocorticoid preparations.
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Hypopigmented
y Vitiligo, pityriasis alba, postinflammatoryhypopigmentation, tuberculoid leprosy.
Scaling Lesionsy Tinea corporis, seborrheic dermatitis, pityriasis rosea,
guttate psoriasis, nummular eczema.
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Diagnosisy Clinical findings, confirmed by positive KOH
preparation findings.
Course and Prognosisy Infection persists for years if predisposing conditions
persist. Dyspigmentation persists for months afterinfection has been eradicated.
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Topical agents
Selenium sulfide (2.5%) lotion or shampooApply daily to affected areas for 10 to 15 min, followed byshower, for 1 week
Ketoconazoleshampoo Applied same as selenium sulfide shampoo
Azole creams (ketoconazole, econazole, micronazole,clotrimazole)
Apply qd or bid for 2 weeks
Terbinafine 1% solution Apply bid for 7 days
Systemic therapy
Ketoconazole 400 mg stat (take 1 h before exercise)
Fluconazole 400 mg stat
Itraconazole 400 mg stat
Secondaryprophylax
is Ketoconazoleshampoo once or twice a weekSelenium sulfide (2.5%) lotion or shampoo
Salicylic acid/sulfur bar
Pyrithionezinc (bar or shampoo)
Ketoconazole400 mg PO monthly