Chapter 28: Vitiligo

INTRODUCTION

Vitiligo is an acquired idiopathic condition that produces symmetric depigmented patches of the skin. It is particularly distressing and clinically apparent in patients with darker skin phototypes.

EPIDEMIOLOGY

Incidence: approximately 2% of the world population

Age: can present at any age but most commonly presents in the second to fourth decade

Race: equal

Sex: equal

Precipitating factors: inheritance, trauma, illness, emotional states

PATHOGENESIS

Unknown.

DERMATOPATHOLOGY

There are no melanocytes in basal cell layer.

PHYSICAL LESIONS

Patients display well-demarcated, symmetric, depigmented, chalk-white macules. Common locations include elbows, knees, sacral area, penis, perioral areas, and neck. Hair may also lose pigmentation (Figs. 28.1 and 28.2).

DIFFERENTIAL DIAGNOSIS

Chemical leukoderma, postinflammatory hypopigmentation, nevus depigmentosus, nevus anemicus, pityriasis alba, lupus erythematosus, leprosy, and genodermatoses.

LABORATORY EXAMINATION

Wood’s lamp examination is helpful in making the diagnosis. In cases of uncertainty, biopsy should be performed of both lesional and nonlesional skin in order to determine if there is an absence of melanocytes in the affected skin. Check thyroid-stimulating hormone (TSH) for hypothyroidism.

COURSE

Vitiligo can pursue a variable course. After an initial rapid presentation, it tends to stabilize. Typically, it is a chronic disease with periods of partial repigmentation but not resolution. It may improve in the summertime. In some cases, depigmentation becomes extensive.

KEY CONSULTATIVE QUESTIONS

• Age of patient

• Time of onset

• Family history

• Occupation

• Chemical exposures

MANAGEMENT

There are multiple treatment modalities for vitiligo. Unfortunately, treatment is frustrating and often ineffective. Patients understandably are distressed by the appearance of vitiligo and desire treatment. In extensive cases, it produces a striking appearance, particularly for patients with darker skin phototypes.

PREVENTION

Sunscreens and sun avoidance protect vitiliginous skin from burning and are an important component of therapy. Further, tanning unaffected skin will accentuate the contrast between normal and vitiliginous skin, worsening the cosmetic appearance of the disease.

TOPICAL TREATMENT

There are a host of topical treatments for vitiligo. They include

• Corticosteroids

  • – Topical

  • – Intralesional

• Calcineurin inhibitors: tacrolimus, pimecrolimus

• Monobenzylether of hydroquinone

  • – Produces permanent depigmentation

  • – Twice daily over 1-year period

  • – Permanent depigmentation is ...