Acquired Speckled Acrofacial Hypomelanosis: A Novel Case Report

Speckled, confetti, or guttate pigmentary disorders include conditions with overlapping features and diagnostic challenges. These disorders present considerable clinical overlap with frequent diagnostic difficulties due to variable phenotypic expression.

A 9-year-old Saudi female presented with a 1-year history of asymptomatic skin lesions involving the face, forearms, hands, legs, and feet. The lesions appeared spontaneously and remained unchanged since onset. Examination revealed 1-3 mm, well-defined, multiple, speckled hypopigmented-to-depigmented macules with bilateral symmetrical distribution. Wood's lamp examination revealed no pigment accentuation. Dermoscopic examination showed well-defined, marginated hypopigmented macules with feathery margins. Microscopic examination, including special DOPA staining, revealed normal melanin pigmentation in the basal keratinocyte layer and normal to focal slightly reduced numbers of basal melanocytes, along with a focal sparse superficial perivascular mononuclear inflammatory cell infiltrate. Based on clinicopathological correlation, a diagnosis of acral speckled guttate hypomelanosis was made. The patient responded well to 1% pimecrolimus cream twice daily.

This case represents a novel presentation of acquired speckled acrofacial hypomelanosis with unique findings, including facial involvement and absence of hyperpigmentation. The patient's excellent response to pimecrolimus cream suggests this may be an effective treatment option for this rare condition.