I love watching and playing tennis.
I also can’t help but play a game I call “observational dermatology.”
In this round, I discuss a likely a case of a common and benign but frustrating skin disease called pityriasis versicolor.
This is Canadian tennis player and now U.S. Open Women’s Doubles Champion Erin Routliffe.
Congratulations to her and her partner, Gabriela Dabrowski! 🏆
As I was watching the trophy presentation, I couldn’t help but notice the lighter colored patches on her shoulders and upper torso. Welcome to my brain.
It’s important to note that this is not about staring, which can make people feel uncomfortable and is inappropriate. It’s also not about looking for “abnormalities” in strangers, especially in cases where someone is afflicted with something that may cause them distress. As a dermatologist, though, I tend to notice these things and can’t help but speculate since diagnosis based on observation is a big part of my job.
I don’t imagine Ms. Routliffe would mind a bit of speculation in the name of dermatology education.
There’s no way to diagnose this definitively without learning more about it, but it’s still interesting to ponder. Observational dermatology isn’t about making a correct diagnosis or objectifying someone — it’s about looking and thinking. It helps keep my detective skills sharp and can also be educational.
Taking into account how common this disease is (especially in the summer months and with sweating) compared to the other entities that would appear in a dermatologist’s “differential diagnosis” for spots like this, I suspect she is dealing with or recovering from a flare of a common and benign skin disease called pityriasis versicolor.
Fortunately, pityriasis versicolor is usually asymptomatic and is relatively easy to diagnose and treat. The rash itself is caused by a superficial fungal infection of the skin (NOT ringworm, the common term for tinea corporis) caused by a type of yeast in the Malassezia genus. When active, it can look lighter or darker than your normal skin color. In folks with lightly pigmented skin, it sometimes looks pink. The shoulders and upper trunk are commonly affected areas.
After treatment (typically with topical or oral anti-yeast medications), the previously affected areas usually become hypopigmented, similar to what can be seen in these photos. The skin pigment often takes months to return to normal, which can be frustrating and can also make someone think the treatment didn’t work. Counseling about this and setting realistic expectations is important.
Another less common disease to consider when you see spots like this is vitiligo, which is an autoimmune-mediated loss of pigment producing cells that results in patchy areas of completely depigmented skin (as opposed to hypo-pigmented skin as in many cases of pityriasis versicolor).
Other things that should be in the differential diagnosis just based on these images include pityriasis alba, lichen sclerosus, post-inflammatory hypopigmentation, medication or chemical-induced leukoderma, discoid lupus erythematosus, morphea, and the hypopigmented variant of cutaneous T-cell lymphoma (mycosis fungoides).
Have you ever struggled with pytriasis versicolor? What was the most difficult part? What worked particularly well for you? Let us know in the comments.
