Vitiligo

Snapshot

• A 19-year-old African American woman presents to her dermatologist for evaluation of white patches on her skin. She reports white patches developing on her hands, face, and chest in the past few months. She has been covering them up with makeup powder but admits to feeling depressed because of the lesions. Her past medical history includes autoimmune thyroid disease. Physical exam reveals multiple sharply demarcated macules and patches of depigmentation. She is started on phototherapy.

Introduction

• Clinical definition
  • autoimmune disease characterized by depigmentation due to loss of epidermal melanocytes    
• Epidemiology
  • demographics
    • onset between 10-30 years of age
  • risk factors
    • family history of vitiligo
• Pathogenesis
  • exact mechanism is unknown
  • theories include
    • autoimmune attack on melanocytes
    • stress leading to neurogenic factors that affect melanocyte survival
    • reactive oxygen species attack on melanocytes
• Associated conditions
  • vitamin D deficiency
  • thyroid disease
  • alopecia areata
• Prognosis
• chronic disease that waxes and wanes

Presentation

• Symptoms 
  • asymptomatic
• Physical exam
  • depigmented patches (not just lack of a tan or hypopigmentation)
    • sharply demarcated white lesions
  • Wood lamp can highlight these areas
• lesions will be fluorescent

Studies

• Biopsy
  • rarely needed
  • only done when clinical diagnosis is unclear
• Histology
  • absence of melanocytes on tissue slide
• loss of epidermal pigmentation

Differential

• Tinea versicolor 
• Pityriasis alba 

Treatment

• Conservative
  • cosmetic camouflage
    • indication
      • for patients who wish to camouflage the vitiligo patches           
    • modalities
      • temporary makeup to color skin
      • tattoo
      • bleaching skin to produce uniform color
  • sunscreen
    • indications
      • to protect against sunlight
• Medical
  • topical treatments
    • indication
      • for localized disease
    • drugs
      • corticosteroids
      • calcineurin inhibitors
  • phototherapy
    • indication
      • for widespread disease
      • used often with topical vitamin D analogs or oral corticosteroids
    • modalities
      • narrowband ultraviolet B
      • psoralen with ultraviolet A
  • oral corticosteroids
    • indications
• used either alone or with phototherapy

Complications

• Poor quality of life and psychologic burden