Diagnosing and treating pediatric patients with skin of color requires a nuanced eye and an understanding of unique psychosocial dynamics. At the latest Skin of Color Update (SOCU) conference, Dr. Karan Lal addressed these exact complexities. Written from the perspective of an attending dermatology resident, this summary breaks down Dr. Lal’s essential pearls across three major domains: pigmented nail disorders, pediatric scarring alopecias, and pigmentary changes in younger patients.
Pigmented Nail Concerns in Children
Dr. Lal began with diffuse idiopathic melanonychia of childhood, a condition driven by melanocyte activation in the nail matrix. It often presents as a gray band in children with darker skin tones, historically labeled as “racial hypermelanosis,” though ethnic pigmentation is now the preferred terminology. Nail trauma, including habits such as biting or exposure to slime, can contribute to these pigment changes.
To address whether nail lesions behave differently in children, Dr. Lal reviewed data from Cooper et al., which evaluated 30 pediatric cases of melanonychia striata for melanoma features including Hutchinson sign, band width, evolution, color, and nail dystrophy. Histopathologic diagnoses included subungual lentigo in 20, subungual nevus in 5, and atypical melanocytic hyperplasia in 5 patients. The thumb was identified as the most affected digit.
In terms of pediatric subungual melanoma, only 12 reports in the literature exist (10 MIS and 2 metastatic). Frequent copy number gains of RREB1, CCND1 and MYC and loss of MYB were identified and have been reported in adult subungual melanomas. It is important to perform a nail matrix biopsy in nail lesions with evolving pigment and widening even in young patients.
Scarring Hair Loss in Children
Dr. Lal discussed the typical presentation of LPP in children, which includes scarring, perifollicular erythema, scaling and plugging, along with atrophy and follicular hyperkeratotic papules, located most frequently on the vertex. He noted a male predominance was observed in one study, which correlates with his clinical practice of seeing more male pediatric patients with this condition.
Dr. Lal also reviewed pearls for recognition of central centrifugal cicatricial alopecia (CCCA), including asking about family history of CCCA in first degree relatives. He underscored the importance of not assuming that there is no hair loss in patients with an afro or a patient who has their hair up. It is very important during the physical exam to spread the hair to be able to see the scalp and identify areas of activity. Dr. Lal also advises to biopsy all forms of hair loss in SOC adolescents given the increasing incidence of inflammatory scarring alopecias.
Pigmented Purpuric Dermatosis (PPD)
A case of eczematid-like purpura of Doucas and Kapetanakis in a 15-year-old female illustrated the spectrum of PPD presentations in children with SOC. The patient demonstrated improvement with rutoside and ascorbic acid therapy.
Dr. Lal cited a retrospective review of pediatric patients with PPD showing:
Most common subtypes:
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- Lichen aureus (43%)
- Schamberg disease (34%)
Treatment varied: vitamin C, rutoside, combination therapy, or observation
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- 45.3% experienced clearance overall
- 10 patients (42%) cleared in the treated group
- 14 patients (58%) cleared in the untreated group
Importantly, no cases progressed to T-cell dyscrasias within the review period. However, Dr. Lal highlighted separate case reports, including PPD evolving into mycosis fungoides, particularly in linear and non-linear variants. He emphasized maintaining clinical vigilance and including CTCL in the differential diagnosis when appropriate.
Distinguishing Vitiligo from Lichen Sclerosus in a Pediatric Population
A clinical comparison highlighted overlapping and distinguishing features:
| Feature | Vitiligo | Lichen Sclerosus (LS) |
| Pruritus | 33.3% | 70% |
| Vulvar pain | No | Yes |
| Pain with defecation | No | Yes |
| Bleeding | No | Yes |
| Figure-of-8 involvement | Possible | Possible |
| Clitoral involvement | Possible | Possible |
Awareness of symptom pattern is especially important in children, where discomfort or embarrassment may limit disclosure.
Managing Progressive Universal Vitiligo: Ethical and Psychosocial Considerations
Dr. Lal presented the case of a 16-year-old Indian male with >50% BSA vitiligo who experienced significant social and cultural stigma. The decision to pursue depigmentation with MBEH requires comprehensive evaluation, particularly in adolescents still establishing self-identity.
Guidance for depigmentation consideration:
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- Best suited for patients with near-universal disease or patients with <50% BSA but with SOC
- Must include evaluation of psychosocial readiness: confidence, self-concept, support system, future goals
- Assess history and chronicity of disease, previous therapies, and check thyroid antibodies if disease is widespread
- Thorough counseling involving the patient and caregivers is critical due to irreversible effects and a lack of data on pediatric long-term outcomes
If appropriate, MBEH initiation may include: 20% monobenzyl ether of hydroquinone (MBEH) applied nightly to a test area (upper inner arm) for 4 weeks, assessing response before broader application.
For patients strongly motivated for repigmentation instead, options may include:
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- Narrowband UVB
- Off-label tofacitinib
- Oral pulsed low-dose dexamethasone
If psychological factors such as depersonalization are identified, Dr. Lal recommended involving mental health specialists prior to or instead of depigmentation efforts.
Take-Home Points
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- Pigmented nail bands are common and usually benign in children with SOC, however concerning features still require a biopsy as is seen in adults
- PPD warrants clinical monitoring for potential CTCL evolution
- Vulvar pigmentary change in children should prompt evaluation for LS vs vitiligo and symptoms can help distinguish between the two, although should be used in conjunction with clinical evidence
- MBEH in adolescents requires careful ethical, psychological, and cultural consideration
References:
Bellet J. S. (2021). Nail discoloration in pediatric skin of color patients. Pediatric dermatology, 38 Suppl 2, 37–41. https://doi.org/10.1111/pde.14659
Cooper, C., Arva, N. C., Lee, C., Yélamos, O., Obregon, R., Sholl, L. M., Wagner, A., Shen, L., Guitart, J., & Gerami, P. (2015). A clinical, histopathologic, and outcome study of melanonychia striata in childhood. Journal of the American Academy of Dermatology, 72(5), 773–779. https://doi.org/10.1016/j.jaad.2015.01.010
Das, K., Soliman, M., Naroji, S., Habeshian, K., & Gomez-Lobo, V. (2024). 30. Comparison of Signs & Symptoms among Pediatric Patients with Lichen Sclerosis (LS) & Vitiligo: Preliminary Findings from an Interdisciplinary Vulvar Dermatology Clinic. Journal of Pediatric and Adolescent Gynecology, 37(2), 249.
Hanna, S., Walsh, N., D’Intino, Y., & Langley, R. G. (2006). Mycosis fungoides presenting as pigmented purpuric dermatitis. Pediatric dermatology, 23(4), 350–354. https://doi.org/10.1111/j.1525-1470.2006.00259.x
Jacob, M., Wright, R., Mazur, L., & Aly, F. (2018). Pigmented purpuric dermatosis. J Paediatr Neonatal Dis, 3(1), 107.
Ollech, A., Paller, A. S., Kruse, L., Kenner-Bell, B., Chamlin, S., Wagner, A., Shen, L., Yousif, R., Balmert, L. C., & Mancini, A. J. (2020). Pigmented purpuric dermatosis in children: a retrospective cohort with emphasis on treatment and outcomes. Journal of the European Academy of Dermatology and Venereology : JEADV, 34(10), 2402–2408. https://doi.org/10.1111/jdv.16397
Papierzewska, M., Waśkiel-Burnat, A., & Rudnicka, L. (2025). Lichen Planopilaris in Children: A Systematic Review. Pediatric dermatology, 42(1), 22–30. https://doi.org/10.1111/pde.15835
This summary was prepared by Dr. Courtney Hanna, Dermatology Resident, who attended the session. The content reflects the resident’s notes and interpretations, may contain errors, and is provided for educational purposes only. It does not constitute official faculty endorsement and should not replace original sources or clinical judgment.
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