Hypopigmented macules: leprosy, atopy or pityriasis versicolor?

Lepromatous leprosy (LL) represents the highest infective and multibacillary form of leprosy. Clinical manifestations are consequent to the haematogenous spread of bacilli and include macules, plaques and nodules in a symmetric distribution or a diffuse infiltration of the skin. LL may mimic many different inflammatory and neoplastic skin diseases and in a small percentage of patients, skin manifestation may be atypical. This article reports the case of a South American child with LL presenting with symmetrically distributed hypopigmented macules previously misdiagnosed as pytiriasis alba, atopic dermatitis and pityriasis versicolor. Atopy and pityriasis versicolor are common skin conditions that can be also observed in leprosy patients and that can masquerade the diagnosis of LL, especially if occurring in dark skin. Dermatologists in Europe should be aware of this unusual form of presentation of leprosy and must take in mind Hansen disease in the differential diagnosis in patients coming from endemic areas.