Pigment

Vitiligo

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Vitiligo

  • Pathophysiology
  1. Immune-mediated Melanocyte destruction
  2. Family History present in up to 30% of patients
  • Epidemiology
  1. Affects 0.5 to 2% of the population
  2. Onset peaks between age 10-30 years (50% occur by age 20 years)
  3. Occurs equally in men and women
  • Types
  1. Localized Vitiligo or Segmental Vitiligo (seen more in children)
    1. Stable involvement, stops progressing at a young age
    2. Affects a small body area or unilateral single Dermatome or extremity involved
  2. Generalized Vitiligo or Nonsegmental Vitiligo
    1. Affects >10% of body surface area, typically bilateral and symmetric
    2. Progresses over time
  3. Acral or Acrofacial Vitiligo
    1. Lip-Tip pattern: Face and distal extremities
  • History
  1. Triggers
    1. Recent stress, illness or local Trauma
  • Signs
  1. Sharply demarcated, white, unpigmented or hypopigmented Macules 0.5 to 5 cm in size
    1. May coalesce together
  2. More noticeable on dark skin
  3. Distribution
    1. Face and neck
    2. Dorsal hands
    3. Genitalia
    4. Intertriginous folds and axillae
    5. Periocular, periumbilical, and perianal areas
  • Associated Conditions
  1. Thyroid disease (Hypothyroidism, Hyperthyroidism)
  2. Pernicious Anemia
  3. Diabetes Mellitus
  • Management
  1. Approach
    1. Head an neck lesions respond better to treatment than extremity and genital lesions
    2. Combination therapy is more effective than monotherapy, but often refractory to any treatment
    3. Recurrence is common (40% of cases)
  2. Localized Vitiligo Management
    1. Topical Corticosteroids, high potency, class II-III (safest and most effective localized treatment)
      1. Safest and most effect
      2. Betamethasone 0.1% ointment
      3. Fluocinonide 0.05% ointment
    2. Topical Calcineurin Inhibitors
      1. Tacrolimus (Protopic)
      2. Pimecrolimus (Elidel)
    3. Surgical grafting
      1. May be used for localized, stable lesions
      2. Split thickness graft
      3. Suction Blister epidermal grafting
  3. Generalized or refractory Vitiligo Management (by Dermatology)
    1. Narrowband Ultraviolet B or UVB (safest and most effective generalized treatment)
    2. Phototherapy with Psoralens or PUVA
    3. Systemic Corticosteroids
    4. Depigmentation (indicated for >40-50% of BSA involvement)
      1. Permanent depigmentation with Monobenzone 20% cream (no longer available in U.S.)
      2. Cryotherapy and laser therapy has been used as an alternative
      3. Requires 6-18 months for full treatment
  4. Cosmetic
    1. Concealers (e.g. Dermablend, Covermark)
    2. Topical dyes
    3. Sunless self-tanning products (skin types 2-3)
  • Prevention
  1. Sun protection is critical (clothing, Sunscreen)
  • References
  1. Njoo (1999) Arch Dermatol 135(12):1514-21 [PubMed]
  2. Plensdorf (2017) Am Fam Physician 96(12): 797-804 [PubMed]
  3. Plensdorf (2009) Am Fam Physician 79(2): 109-16 [PubMed]