Photo Quiz

White Lesions on the Hands and Lower Extremities


Am Fam Physician. 2019 Jan 15;99(2):125-126.

A 16-year-old girl presented with asymptomatic, white lesions on the hands and lower extremities. The lesions were first noted five years earlier and had slowly increased in size. There was no family history of a similar skin disorder or autoimmune disease.

Physical examination revealed well-demarcated, chalk-white macules and patches on the dorsum of the hands (Figure 1) and extensor aspects of the legs.

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Based on the patient's history and physical examination findings, which one of the following is the most likely diagnosis?

A. Hypomelanosis of Ito.

B. Idiopathic guttate hypomelanosis.

C. Pityriasis alba.

D. Tinea versicolor.

E. Vitiligo.


The answer is E: vitiligo. Vitiligo is characterized by asymptomatic, acquired, amelanotic macules and patches that are milky or chalk-white in color.1 Lesions are well demarcated, often symmetrical, and show homogenous depigmentation. The most common location is the face, followed by the neck, limbs, and trunk. The onset of vitiligo occurs before 10 years of age in 25% of patients, before 20 years in 50% of patients, and before 40 years in 95% of patients.1

In most patients, the disease is slowly progressive, with the appearance of new lesions or enlargement of existing lesions. Vitiligo is more common in those who have a family member with the condition. The cause of vitiligo is unclear, but the patches of depigmented skin are due to the loss of melanocytes.

Hypomelanosis of Ito is characterized by patterned, hypopigmented macules in well-demarcated streaks, stripes, whorls, and patches. It usually involves more than two body

Address correspondence to Alexander K.C. Leung, MBBS, at Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


1. Leung AK, Barankin B, Hon KL. Vitiligo. Pediatr Neonatal Care. 2013;1(1):103. Accessed November 15, 2018.

2. Qualia CM, Brown MR, Leung AK, et al. Index of suspicion. Pediatr Rev. 2007;28(5):193–198.

3. Leung AK, Feingold M. Pityriasis alba. Am J Dis Child. 1986;140(4):379–380.

This series is coordinated by John E. Delzell Jr., MD, MSPH, Associate Medical Editor.

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