A 2-year-old boy was brought with multiple pale macules over the upper chest noted by parents over the past year. The lesions were asymptomatic, non-scaly, and had gradually increased in number. On detailed inquiry, the mother gave a history of application of warm crushed betel (Piper betle) leaves on the chest during respiratory illnesses, a home remedy commonly practiced in their native village in Tamil Nadu. Examination revealed multiple, well-defined, hypopigmented macules without scaling or atrophy, over the chest (Fig. 1). Wood’s lamp showed no accentuation, and potassium hydroxide (KOH) mount was negative, which helped to exclude underlying vitiligo and pityriasis versicolor, respectively. Considering the history, a diagnosis of contact leukomelanosis due to betel leaves was considered. A confirmatory patch test could not be performed due to parental reluctance. The family was counseled to stop the practice of local application of betel leaves, and topical corticosteroids were prescribed. On follow-up, partial repigmentation was observed at the end of 3 months.

Multiple well-defined hypopigmented macules over the chest

Heated betel leaves are traditionally applied to the chest of children during respiratory illnesses in several Indian states such as West Bengal, Odisha, Tamil Nadu, and Andhra Pradesh. The betel leaf contains bioactive compounds such as eugenol and chavicol, which can cause melanocyte damage, especially with prolonged exposure after topical application. The resulting depigmentation or hypopigmentation may be mistaken for vitiligo or pityriasis versicolor. The absence of scaling, segmental arrangement, or progression to well-demarcated lesions helps differentiate it from those conditions. Lack of Wood’s lamp fluorescence and a negative KOH preparation further aid diagnosis. Ash leaf macules, seen in tuberous sclerosis, are an important differential diagnosis and typically present as hypopigmented, elliptical or lance-ovate macules, commonly over the trunk and limbs. Recognition of this contact leukomelanosis is especially important in rural or semi-urban populations where traditional remedies are common. Management involves discontinuing the application and use of topical anti-inflammatory agents. This case highlights the need for cultural sensitivity and anticipatory guidance in pediatric dermatology.