Pallor is abnormal paleness or loss of skin color, which may develop suddenly or gradually. It can be generalized, affecting the entire body, or localized to a single limb. Generalized pallor is most evident on the face, conjunctiva, oral mucosa, and nail beds, while localized pallor is usually confined to a limb or digits.

Detection of pallor varies with skin tone and the vascularity or thickness of subcutaneous tissue. In dark-skinned individuals, pallor may be subtle and observable only on the conjunctiva or oral mucosa.

Pallor may result from:

1. Decreased peripheral oxyhemoglobin, due to vasoconstriction, arterial occlusion, or low cardiac output.

2. Decreased total oxyhemoglobin, typically caused by anemia, the most common cause.

Emergency interventions

• Sudden generalized pallor may indicate shock.

• Assess for tachycardia, hypotension, oliguria, and decreased level of consciousness (LOC).

• Prepare to infuse fluids or blood rapidly.

• Obtain hemoglobin, hematocrit, and serum glucose levels.

• Keep resuscitation equipment readily available.

History and Physical Examination

History

• Ask about personal or family history of anemia, chronic disorders (renal, heart failure, diabetes).

• Evaluate dietary intake of iron-rich foods (red meat, green vegetables).

• Determine onset, duration, and triggers: constant or intermittent, exposure to cold, emotional stress.

• Explore associated symptoms: dizziness, fainting, orthostasis, fatigue, dyspnea, chest pain, palpitations, menstrual irregularities, loss of libido.

• For localized pallor: ask about pain, numbness, tingling, or intermittent claudication in affected limbs or fingers.

Physical Examination

• Check vital signs, including orthostatic blood pressure.

• Auscultate heart for murmurs or gallops and lungs for crackles.

• Evaluate skin temperature: cold extremities may suggest vasoconstriction or arterial occlusion.

• Inspect for ulceration or cyanosis.

• Examine abdomen for splenomegaly.

• Palpate peripheral pulses: absent pulse suggests arterial occlusion; weak pulse may indicate low cardiac output.

Medical causes

Special considerations

• Chronic generalized pallor may require blood studies or bone marrow biopsy.

• Localized pallor may need arteriography or other vascular studies.

• Treat low cardiac output with blood/fluid replacement, diuretics, cardiotonics, and antiarrhythmics as indicated.

• Monitor vital signs, intake/output, ECG, and hemodynamic status.

Patient counseling

• For anemia: explain importance of iron-rich diet and rest.

• For frostbite and Raynaud’s: advise on cold protection measures.

• For orthostatic hypotension: teach slow position changes.

• Discuss warning signs to report: severe dizziness, fainting, chest pain, cold extremities, or new ulcers.

Pediatric pointers

• Causes are generally similar to adults.

• Additional causes include congenital heart defects or chronic lung disease.

• Pallor in infants may be subtle and visible mainly on conjunctiva, oral mucosa, or nail beds.

References

1. Berkowitz CD. Berkowitz’s Pediatrics: A Primary Care Approach. 4th ed. USA: American Academy of Pediatrics; 2012.

2. Buttaro TM, Tybulski J, Bailey PP, Sandberg-Cook J. Primary Care: A Collaborative Practice. St. Louis, MO: Mosby Elsevier; 2008.

3. Colyar MR. Well-child Assessment for Primary Care Providers. Philadelphia, PA: F.A. Davis; 2003.

4. McCance KL, Huether SE, Brashers VL, Rote NS. Pathophysiology: The Biologic Basis for Disease in Adults and Children. Maryland Heights, MO: Mosby Elsevier; 2010.

5. Sommers MS, Brunner LS. Pocket Diseases. Philadelphia, PA: F.A. Davis; 2012.