Hypopigmented Patches Research Articles

Consider antilaminin gamma-1 pemphigoid when faced with conflicting histopathology and immunofluorescence results

To the Editor: A 69-year-old man presented with a 2-month history of widespread pruritic vesiculobullous lesions. He denied any mucosal involvement or systemic symptoms. Physical examination revealed tense vesicles and bullae present on the face and the upper and lower extremities along with many hemorrhagic crusted erosions and hypopigmented atrophic patches (Fig 1).

Hypopigmented Patches on the Skin

A 47-YEAR-OLD MAN PRESENTS WITH A 1-YEAR HISTORY OF A MILDLY pruritic eruption on the trunk and extremities. He has no significant medical history and takes no medications. He denies any recent travel or close contact with persons or animals having a similar eruption. Review of systems is negative. On physical examination, he has hypopigmented round patches with fine cigarette-paper scaling centrally located on his proximal arms, hips, thighs, lateral chest wall, and flanks (FIGURE 1). Sensation is intact over the affected skin. Examination of skin scrapings using potassium hydroxide is negative for hyphae, and there is no palpable lymphadenopathy. What Would You Do Next?

Hypomelanosis of Ito: A rare cutaneous syndrome

Hypomelanosis of Ito, also known as Incontinentia Pigmenti Achromians of Ito (IPA), is a rare cutaneous syndrome clinically characterized by macular hypopigmented whorls, patches, and streaks either unilateral or bilateral following lines of Blaschko. These skin lesions become apparent at birth or during childhood and normally are present on the trunk, occasionally on the extremities, and rarely on the face. Most patients have multisystem involvement and may show chromosomal mosaicism, the most common being neurological, muscular, skeletal, and ocular. We present a male child of 5-years-old with hypopigmented whorls and patches along the lines of Blaschko present on both sides of the trunk since birth. The child had no other systemic abnormality. The importance of this cutaneous condition and its association with other system involvement has been emphasized in this article.

Erythematous, firm, papular lesions over the face

A 63-year-old female presented with a history of multiple asymptomatic, erythematous, non-indurated papules and plaques on the upper lip, below the nose, above the medial end of both eyebrows, and in front of both the ears, of 5 years duration [Figures 1 and 2]. The patient denied of having any other symptoms of itching, photosensitivity, chest pain, weight loss, and was otherwise in good health. Her baseline investigations were within normal limits and chest X-ray showed bilateral hilar lymphadenopathy. A skin biopsy was done from the face, which showed epitheloid cell granulomas in the dermis [Figures 3 and 4].Figure 1: Multiple erythematous firm papular lesionsFigure 2: Closer view demonstrates the lesional morphologyFigure 3: Histopathologic photograph in low powerFigure 4: Better visualization in 100×DISCUSSION Sarcoidosis is a multi-system disease characterized by epitheloid cell tubercles without caseation although fibrinoid necrosis may be present at the center of few, proceeding either to resolution or to conversion of epitheloid tubercles into hyaline fibrous tissue.[1] Between 20 and 35% of patients with systemic sarcoidosis have skin lesions, but cutaneous sarcoidosis can also occur in the absence of systemic involvement.[23] Recognition of cutaneous lesions is important because they provide a visible clue to the diagnosis and are an easily accessible source of tissue for histologic examination.[4] Because lesions can exhibit many different morphologies, cutaneous sarcoidosis is known as one of the “great imitators” in dermatology.[3] Specific manifestations include papules, plaques, lupus pernio, scar sarcoidosis, and rare morphologies suchas alopecia, ulcers, hypopigmented patches, and ichthyosis.[56] Treatment of cutaneous lesions can be frustrating. The most effective treatment for patients with severe lesions or widespread is systemic corticosteroids.

Segmental Lentiginosis and Hypomelanosis of Ito with Bilateral Lisch Nodules: Is it an Unusual Presentation of Segmental Neurofibromatosis?

Observation: We here report a 16 year-old Turkish girl with an unusual combination of hiperpigmented macules and hypopigmented patch on her right face and neck region with a sharp demarcation to the midline. Her mother defined that they had first appeared when she was two years old. Bilateral lisch nodules in both eyes were determined through the ophthalmologic examination. While histopathology of a brown macule revealed the features of lentigo and hypopigmented patch showed the features of hypomelanosis of Ito the diagnosis of segmental (NF) was made on the basis of these clinical features and the absence of family history and systemic involvement. However bilateral Lisch nodules were found to be a rare accompanying disorder in segmentel NF, we suggest that our patient have a subtype of this entity. Although we could not demonstrate the genetic mutation, the clinical and histopathological findings indicate us the somatic mosaicism.

Malassezia species isolated from lesional and nonlesional skin in patients with pityriasis versicolor

Objectives This study aimed to identify Malassezia species found in pityriasis versicolor (PV) patients as well as to establish whether there is any association between the various species of Malassezia isolated from lesional and from nonlesional skin of those patients. Background PV is a common, benign, superficial cutaneous fungal infection caused by Malassezia species usually characterized by hypopigmented or hyperpigmented macules and patches on the chest and back. These lesions are scaly and their color varies from red, pale, yellow brown to dark brown. Patients and methods A total of 100 patients with PV were included in the study. The samples were obtained by scraping the skin surface, both from lesional and from nonlesional skin, and then incubated on Dixon's agar. The yeast isolated were identified using conventional biochemical tests and Tween assimilation. Results Skin lesions were 100% KOH positive for Malassezia species and 10% KOH positive in healthy skin. Growth from skin lesion was obtained on Dixon's agar in 83 patients (83%). The most common species was Malassezia furfur as it was detected in 47 samples (47%), followed by Malassezia globosa (23%) and Malassezia sympodialis (13%). From healthy skin of patients, growth of Malassezia was obtained from 19 specimens, M. furfur was detected in 13%, and M. globosa was detected in only three patients (3%) and M. sympodialis in three patients (3%). Conclusion M. furfur in its mycelial phase was the predominant species involved in the etiology of PV and M. globosa was the second most common species. The most frequently isolated species from clinically healthy skin was M. furfur and was recovered from healthy skin only in yeast form. We found no difference in the distribution of Malassezia species between lesional and nonlesional skin. Furthermore, no species predominance was observed whether with hyperpigmented or hypopigmented lesions as M. fufur was the most common species in both lesions in PV patients.

Localized Involutional Lipoatrophy in a Child

Dear Editor: Localized loss of adipose tissue without prior clinical or histologic inflammation is usually termed idiopathic lipoatrophy1. Localized involutional lipoatrophy (LIL), which was first described by Peters and Winkelmann2 in 1986, generally appears asymptomatic well-demarcated, depressed lesion on a single or in several sites3. Most of the reported cases occur in adolescence or in adulthood, but there has been only one reported childhood case of LIL2. Thus, we report a rare case of LIL in childhood in which triggering factors are not found and we reviewed the previously published reports. A 5-year-old boy presented with an asymptomatic depressed lesion on his right buttock 1 month ago. The patient denied any history of injury or local injection at that site. He had no other medical problems or any associated drug intake. Physical examination revealed a well-demarcated, 3.0×3.5 cm sized hypopigmented, depressed atrophic patch (Fig. 1). Laboratory examination showed no abnormal findings in the patient's complete blood count, blood chemistry, C-reactive protein level, and autoantibody screening tests for antinuclear, anti-DNA, and anticentromere antibodies. Histopathological examination of a biopsy specimen showed epidermal atrophy and a decrease in the size of subcutaneous fat lobules composed of small adipocytes. There was no significant dermal or subcutaneous inflammation (Fig. 2). Immunohistochemical studies revealed CD68 positive macrophages within the fat lobules. We have followed up this patient without any treatments or procedures for 6 months, but there was no spontaneous regression. Fig. 1 Well-demarcated, hypopigmented, and depressed atrophic patch on the right buttock. Fig. 2 Histological examination of the skin biopsy specimen shows. (A) Epidermal atrophy, compaction of collagen bundle in the dermis without inflammation (H&E, ×40). (B) Diminutive fat lobules composed of variable sizes adipocytes (H&E, ... Peters and Winkelmann2 first reported LIL in 6 patients, most of all patients were adolescence or adult age except one 5-year-old boy. Yamamoto et al.3 reported 6 patients with LIL, all of whom were female, while 4 of the 6 patients had a history of local injections. Dahl et al.1 reported 16 patients with LIL, who had an average age of 32.8 year (range: 13 to 65 year) with female predominance; 9 of 16 patients had a history of antecedent intramuscular or intra-articular injections at the affected sites. Histological examination presented variable sized fat lobules composed of small fat cells embedded in a well-vascularized and hyalinized background. Each adipocyte that resembles fetal fat tissue may vary in size, but are smaller than the normal fat cell3. LIL is also characterized by the presence of CD68-positive and mucin-positive macrophages scattered between the affected lipocytes. Lesional direct immunofluorescence findings are usually negative1,2. The pathophysiology of LIL is still unknown. LIL is associatied with various immunologic disorders, which may suggest a background of immunologic dysregulation that may predispose for the development of LIL lesions after injection of medications such as antibiotics, insulin, or steroids1,3-5. Ultrastructurally, the activated macrophages were shown in close to fat cells. It is believed that these macrophages are activated after injury and secrete many cytokines, such as tumor necrosis factor-α, interleukin 1, platelet-derived growth factor, transforming growth factor-β1, and fibroblast growth factor-2, which may then mediate the involution of the adipose tissue5. In our case, we could not identified any triggering factors. However, we presumed that the cause of our case was any injury that included injection or trauma; most cases of childhood LIL were triggered after injection. In conclusion, most reported cases have occurred in females of adolescent or adult age with a local injection history, but there has been only one report on childhood LIL2. Thus, we think that this case is very interesting in terms of age of onset, gender, and unidentified triggering factor.

Comparison of the Psychological Impacts of Asymptomatic and Symptomatic Cutaneous Diseases: Vitiligo and Atopic Dermatitis

BackgroundVitiligo and atopic dermatitis (AD) are common dermatological disorders which may cause significant psychological and social distress leading to impaired quality of life (QoL) in patients.ObjectiveWe evaluated the degree of psychological stress and impairment of QoL in vitiligo patients as compared with AD patients and normal controls (NCs).MethodsA total of 60 patients from each group and 60 NCs were enrolled. Five questionnaires on depression (Beck depression inventory, BDI), state anxiety (SA) and trait anxiety (TA), interaction anxiousness (IAS), private body consciousness (PBC) and dermatologic QoL were used.ResultsThe vitiligo patients had a significantly higher level of TA (p<0.01), PBC (p<0.001) and impaired QoL (p<0.001) than NCs, but not BDI, SA and IAS. The AD patients had significantly higher scores for all five questionnaire items compared with NCs. In the comparison between the AD and vitiligo groups, all of the indexes except body consciousness were higher in AD patients than in vitiligo patients: BDI (p<0.01), SA (p<0.05), TA (p<0.001), IAS (p<0.01) and impaired QoL (p<0.001). Exposure of vitiligo lesions was not a significant variable in the analysis of the contribution of clinical variables of vitiligo on psychological stress and QoL.ConclusionVitiligo, which is not accompanied by any symptoms, involves less psychological impact than AD, which is accompanied by itching. Compared to NCs, however, the elevated general anxiety and body consciousness in patients with vitiligo suggests that they may be more concerned with the aggravation of hypopigmented patches than difficulties in social interactions.

Tuberous sclerosis – A rare presentation in neonate

Tuberous sclerosis is a neurocutaneous autosomal-dominant disorder, presents with highly variable clinical manifestation and affects multiple organ system. Its manifestation in neonate is poorly described. We report a case of intractable neonatal seizure with multiple hypopigmented patch. Neuroimaging of brain shows classical cortical tubers and subependymal nodule suggestive of tuberous sclerosis in newborn. Hence tuberous sclerosis should be considered as an etiology of neonatal seizure and neuroimaging should be performed when other common causes of neonatal seizure have been excluded. Keywords: Neonatal seizure, Neuroimaging,Tuberous sclerosis

Application of dapsone 5% gel in a patient with dermatitis herpetiformis

Application of dapsone 5% gel in a patient with dermatitis herpetiformis

Atypical fibroxanthoma-like amelanotic malignant melanoma: A case report and literature review

Atypical fibroxanthoma (AFX)-like malignant melanoma is very rare. Here, we report a case of amelanotic AFX-like melanoma in a 72-year-old Taiwanese woman presenting with two separate, asymptomatic, enlarging erythematous nodules within a large hypopigmented patch on her left cheek. Histologically, both lesions showed cellular nodules in the reticular dermis separated from the overlying flattened epidermis by a zone of solar elastosis or fibrosis. The tumor consisted of sheets of atypical epithelioid cells arranged in a vague nesting pattern, as well as many atypical large or gigantic cells with one or more, large hyperchromatic, vesicular, or pleomorphic nuclei with prominent nucleoli, and moderate-to-abundant eosinophilic or foamy cytoplasm. Focal intraepidermal proliferation of atypical melanocytes with a pagetoid pattern was found only in the periphery of the main tumor. The tumor cells were moderately to strongly positive for S-100, Melan-A, and HMB-45. The pleomorphic giant cells were focally CD68-positive but CD163-negative. The patient underwent tumor excision followed by radiotherapy due to the narrow surgical margins. A sentinel lymph node biopsy revealed no metastasis of the melanoma. This case illustrates the importance of scrutinizing any subtle proliferation of atypical melanocytes in the epidermis in an AFX-like tumor in order to avoid misdiagnosis.

Albinism and disease causing pathogens in Tanzania: Are alleles that are associated with OCA2 being maintained by balancing selection?

Oculocutaneous albinism type 2 (OCA2) is present at significantly higher frequencies in sub-Saharan African populations compared to populations in other regions of the world. In Tanzania and other sub-Saharan countries, most OCA2 is associated with a common 2.7kb deletion allele. Leprosy is also in high prevalence in sub-Saharan African populations. The infectious agent of leprosy, Mycobacterium leprae, contains a gene, 38L, that is similar to OCA2. Hypopigmented patches of skin are early symptoms that present with infection of leprosy. In consideration of both the genetic similarity of OCA2 and the 38L gene of M. leprae and the involvement of pigmentation in both disorders, we hypothesized that the high rates of OCA2 may be due to heterozygote advantage. Hence, we hypothesized that carriers of the 2.7kb deletion allele of OCA2 may provide a protective advantage from infection with leprosy. We tested this hypothesis by determining the carrier frequency of the 2.7kb deletion allele from a sample of 240 individuals with leprosy from Tanzania. The results were inconclusive due to the small sample size; however, they enabled us to rule out a large protective effect, but perhaps not a small advantage.Mycobacterium tuberculosis is another infectious organism prevalent in sub-Saharan Africa that contains a gene, arsenic-transport integral membrane protein that is also similar to OCA2. Interestingly, chromosomal region 15q11-13, which also contains OCA2, was reported to be linked to tuberculosis susceptibility. Although variants within OCA2 were tested for association, the 2.7kb deletion allele of OCA2 was not tested. This led us to hypothesize that the deletion allele may confer resistance to susceptibility. Confirmation of our hypothesis would enable development of novel pharmocogenetic therapies for the treatment of tuberculosis, which in turn, may enable development of drugs that target other pathogens that utilize a similar infection mechanism as M. tuberculosis. From an evolutionary perspective, confirmation of our hypothesis may provide another example of heterozygote advantage.

A Rare Case of Colorectal Peripheral T-Cell Lymphoma Associated with Mycosis Fungoides

Purpose: ‘Mycosis Fungoides' (MF) is an indolent T cell lymphoma, involving primarily skin with rare extracutaneous, or visceral involvement occurring in advanced stages of the disease. Gastrointestinal system involvement is very rare and it is associated with significant morbidity and mortality secondary to various complications. We are describing a case of “Peripheral T-Cell Lymphoma” involving the rectum and the colon diagnosed on a screening colonoscopy in a patient with a history of Mycosis Fungoides. A 66-year-old AA man with h/o of HTN, dyslipidemia, and mycosis fungoides was referred by his dermatologist for a screening colonoscopy. He denied any symptoms including weight loss, rectal bleeding, melena, hematemesis or altered bowel movements. His physical exam was notable for diffuse hypopigmented and hyperpigmented patches over the skin, primarily hands and feet. There was no evidence of splenomegaly or lymphadenopathy. He was lost to follow up for five years after a decade of stable disease. He was started on clobetasol topical ointment and narrow band UVB therapy. Colonoscopy showed a large ulcerated mass with greenish black exudate occupying 50-74% of the circumference of the rectum, extending 5cm from entry site up to 17cm. The biopsy showed colonic mucosa diffusely infiltrated by large atypical lymphoid cells with varied size, hyperchromatic nuclei and small nucleoli. Flow cytometry showed abnormal clonal T cell proliferation and stained positive for CD3, CD4, CD5 and rarely for CD8 suggestive of peripheral T cell lymphoma. A molecular study for TCR Gamma rearrangement performed on the previous lymph node biopsy and the current rectal specimen showed identical clonal peaks indicating that the process in the rectum likely represents transformation of the patient's cutaneous T cell lymphoma. A month later, he was admitted to the hospital with severe pain and swelling in his right lower extremity. He was found to be having a diffuse systemic involvement of T cell lymphoma of plural fluid, right thigh, inguinal lymphnodes, and CNS. His prognosis was assessed to be very poor and he was sent to hospice care based on his wishes for comfort care.Figure: No Caption available.

Choroid plexus papilloma in a girl with hypomelanosis of Ito

The authors report a case of choroid plexus papilloma in a girl with hypomelanosis of Ito, and they review the literature in brief. Hypomelanosis of Ito is a rare neurocutaneous syndrome characterized by cutaneous hypopigmented whorls, streaks, and patches along lines of Blaschko. Most patients exhibit CNS manifestations, including psychomotor retardation, seizures, hypotonia, and ataxia. A 6-year-old girl with hypomelanosis of Ito was referred to the authors' hospital with bilateral tumors in the lateral ventricles. The right lateral ventricle tumor was surgically removed. Immunohistochemical investigations revealed the tumor to be a choroid plexus papilloma (WHO Grade I). A chromosomal investigation revealed that the tumor tissue demonstrated a large loss of heterozygosity at chromosome 10. The case reported here serves as a reminder that de novo brain tumors may arise in patients with chromosomal mosaicism.

Annular hypopigmented mycosis fungoides: a novel ringed variant

Hypopigmented mycosis fungoides (MF) is a relatively uncommon variant of cutaneous lymphoma that is mostly seen in darker skin types. We present a novel and unique clinical presentation in an African-American female patient, consisting of regular hypopigmented annular rings in areas of normal skin and in more typical hypopigmented patches of MF. The lesions appeared diffusely on all extremities, anterior chest and back. Histopathologic examination showed an atypical lymphocytic infiltrate at the dermal-epidermal junction with epidermotropism and few Pautrier's collections. The patient was otherwise healthy and improved with narrowband ultraviolet (UV)-B. This case represents a presentation of a most unusual variant of hypopigmented MF, for which we propose the name 'annular hypopigmented MF'.

A Case of Tinea Versicolor of the Eyelids

Tinea versicolor is a commonly encountered superficial fungal infection often presenting on the chest and back with hyperpigmented or hypopigmented scaly macules and patches. We report an unusual and rare presentation of tinea versicolor affecting only the eyelids.

Hypomelanosis Ito and hemimegalencephaly

Aims: The disorder of Hypomelanosis Ito is characterized by unilateral or bilateral macular hypopigmented whorls, streaks, and patches. Neurologic impairment can be quite severe with hemimegalencephaly and/or migration disorders. Affected children often suffer from difficult to treat drug-resistant epilepsy.

Clinicopathologic Profile of Hypopigmented Mycosis Fungoides in India

Hypopigmented mycosis fungoides (HMF) is an under recognized disease in India, which is often mistaken for Hansen disease or vitiligo, resulting in delayed diagnosis and treatment. To describe the clinical, histopathologic and immunohistochemical features of HMF in Indian patients. All cases presenting as hypopigmented lesions that were signed out as MF between 2001 and 2009 (15 cases) were included. Clinical data and histopathology slides were reviewed. Immunostains for CD4, CD8, and CD1a were done, where tissue was available. The age ranged from 14 to 38 years with a male preponderance. The commonest presentation was multiple hypopigmented patches on limbs and trunk with the duration of the lesions varying from 4 months to 14 years. All cases showed a psoriasiform/lichenoid epidermal pattern, disproportionate epidermotropism, basilar tagging of lymphocytes, monomorphous lymphocytes, haloed lymphocytes, and wiry dermal collagen. Other important findings were infiltration of hair follicles, larger epidermal lymphocytes, atypia of dermal lymphocytes, and stuffed dermal papillae. Dermal edema was absent in all cases. Immunohistochemistry done on 10 cases showed a CD8 phenotype in 6 cases and CD4 phenotype in the remaining 4 cases. Histopathology supplemented by immunohistochemistry is reliable in making a diagnosis of HMF. It is important to be aware of this uncommon, yet significant disease.

Café‐au‐lait macules and intertriginous freckling in piebaldism: Clinical overlap with neurofibromatosis type 1 and Legius syndrome

Piebaldism is an autosomal dominant disorder characterized by congenital hypopigmented patches of skin and hair and has been found to be associated with mutations in the KIT or SLUG genes. Café-au-lait macules (CALM) may occasionally be seen in piebaldism. There are four reports describing six patients who were said to have both piebaldism and neurofibromatosis type 1 (NF1) due to the presence of multiple CALM and intertriginous freckling, but none of these patients had undergone comprehensive NF1 mutation analysis. We describe a large family with piebaldism in which two members meet diagnostic criteria for NF1 based on the presence of >5 CALM and intertriginous freckling. Interestingly, only these two family members are of mixed race, which could be of importance. A novel complex mutation in the KIT gene was identified in several family members affected with piebaldism; the proband meeting diagnostic criteria for NF1 also underwent comprehensive NF1 and SPRED1 testing with no mutations detected. These findings suggest that piebaldism may occasionally include CALM and intertriginous freckling, which may create diagnostic confusion especially in the absence of a family history of piebaldism. However, careful clinical evaluation and molecular testing if necessary should distinguish these two disorders.

Is Spontaneous Disappearance of Nevus Depigmentosus Possible?

Dear Editor: Nevus depigmentosus (ND) is characterized by a congenital hypopigmented macule or patch. The pathophysiology of ND is poorly understood, but likely associated with a functional defect in melanosome transfer from melanocytes to keratinocytes1. ND is known to remain generally stable in size and distribution throughout life1. Herein, we describe a case of a 6-year-old boy whose ND disappeared, suggesting the possibility of spontaneous resolution of ND. A 10-month-old male was brought to our clinic because of whitish patches on his right leg that had been present since his birth. Physical examination revealed hypopigmented patches on the medial side of right thigh (Fig. 1a). A diffuse bluish patch that was suspected to be an aberrant Mongolian spot surrounded the hypopigmented areas. A 2-mm punch biopsy of the hypopigmented patches and adjacent perilesional normal skin at 1 cm from margin was performed. There were no remarkable findings on H&E staining (Fig. 2a). Fontana-Masson staining showed decreased epidermal pigmentation in the lesional skin compared to the perilesional normal skin (Fig. 2b). There was no difference in the number of NKI/beteb positive melanocytes between the lesional and perilesional normal skin (Fig. 2c). These findings were consistent with ND. The patient did not receive any treatment and was lost to follow-up until his recent revisit 6 years later. At that time, he returned with a facial mobiliform eruption, accompanied by fever and conjunctival injection, and was diagnosed with erythema infectiosum. Interestingly, during physical examination, it was noted that the previous ND and the surrounding aberrant Mongolian spot had completely disappeared (Fig. 1b). The patient's parents did not recall the time of the ND disappearance. Fig. 1 Spontaneous disappearance of hypopigmented macules and patches. (a) A 10-month-old male presented with hypopigmented macules and patches on his right thigh in linear configuration since birth. A diffuse bluish patch that was suspected to be an aberrant ... Fig. 2 Histological findings. (a) There were no remarkable findings on H&E staining. (b) Fontana-Masson staining showed decreased epidermal pigmentation in the lesional skin compared to the perilesional normal skin. (c) There was no difference in the ... Spontaneous resolution of ND has never been reported. However, it should be noted that there has been no epidemiological study regarding the fate of ND. Moreover, there have been several reports suggesting the possibility that the functional defect of the melanocytes in ND is reversible2,3. Bardazzi et al.2 described the development of lentigines within ND after narrow band ultraviolet B exposure. They suggested the possibility of partial activation of melanosome transfer, resulting in overproduction of melanin within ND. Oiso et al.3 reported a case of acquired junctional melanocytic nevus development in ND. These cases suggest that melanocytes in ND could transform from a functionally defective stage to an active stage or shift to other forms such as nevus cells. Interestingly, in our case, the ND and Mongolian spots were coexistent at the initial visit and both had disappeared at the next visit. The possible relationship between Mongolian spots and spontaneous regression of ND could be suspected. There was no confirmative diagnosis of ND. It is important to consider the other hypopigmenting conditions, such as postinflammatory hypopigmentation or hypomelanosis of Ito4. Because the lesion was present from birth and he did not have any history of inflammation on the hypopigmented lesion, postinflammatory hypopigmentation could be differed from our case. Hypomelanosis of Ito consists of hypopigmented zones or spots with irregular borders, whorls, patches, or linear streaks with various patterns of distribution5. It follows the lines of Blaschko that represent a peculiar pattern of distribution. In addition, hypomelanosis of Ito usually encounter the extracutaneous manifestation. Reviewed in aspect of distribution of lesions and extracutaneous symptoms, we thought that hypomelanosis of Ito was less likely in our case. Therefore, considering the congenital hypopigmented macules, distribution, and other clinical manifestations, the hypopigmented macules and patches were most likely ND. In conclusion, our case suggests the possibility that ND could disappear. An epidemiological study of ND with long term follow up is further needed to know if ND could disappear, as in our case, or is persistent throughout life.