Vitiligo

Question 1

Define vitiligo

Answer 1

Acquired, chronic depigmentation disorder characterized by selective loss of melanocytes and a chalky white appearance of affected areas of skin (and sometimes hair).

Question 2

What are the types of vitiligo

Answer 2

Non-segmental (85-90%): non-dermatomal and multiple formes
Segmental: earlier age of onset, dermatomal distribution and unilateral

Question 3

Aetiology of vitiligo

Answer 3

Non-segmental vitiligo: melanocyte loss due to autoimmune destruction of melanocytes by lymphocytes, associated with autoimmune disease
Segmental vitiligo: neuronal cause — certain neurochemical mediators released from nerve endings in the epidermis become toxic to melanocytes.

Triggers for onset and relapse:
- Emotional stress or illness.
- Hormonal changes following pregnancy.
- Skin trauma, including the Koebner phenomenon (where depigmentation develops at sites of trauma, such as cuts, abrasions, or sunburn).
- Environmental exposure to chemicals (such as phenolic/catecholic derivatives that may be present in oils, disinfectants, hair dyes, or deodorants for example).

Question 4

Symptoms and signs of vitiligo

Answer 4

Skin lesions
- Depigmentation (pale and hypopigmented → chalky white and depigmented)
- Well-demarcated
- Scalloped borders
- Flat and non-scaly
- Bilateral and symmetrical
- May have a white centre (trichrome vitiligo)
- May appear pink in more vascular areas
- May be itchy
Koebner phenomenon: appears in sites of mechanical trauma e.g. abrasions, burns, friction
Hair roots may be effected: white eyelashes and white hair

Question 5

Management for vitiligo

Answer 5

Conservative:
- Sunblock
- Make-up, skin camouflage service
- Avoid friction and trauma
- Vitiligo society

Medical
- Topical corticosteroids for up to 2 months (off-label)
- Can reverse changes if applied early
- Potent topical steroids
- Topical calcineurin inhibitors e.g. tacrolimus, pimecrolimus
- Phototherapy

Surgical (for stable segmental)
- Grafting technique

Question 6

When should you refer to dermatology for vitiligo

Answer 6

The condition is progressing rapidly.
The diagnosis is uncertain.
The person has segmental vitiligo.
The face is affected.
A child is affected.
A woman is pregnant.
Large areas of the body are affected (more than 10% of the body surface area).
The person is particularly distressed by the condition.
There are contraindications or adverse effects from topical corticosteroid treatment.
Initial treatment in primary care has been unsuccessful (2 months steroid)

Question 7

Complications of vitiligo

Answer 7

Psychosocial issues: low self-esteem, embarrassment, stigmatisation, anxiety, depression
Possible increased risk of non-melanoma skin cancers (NMSCs) — especially on depigmented areas of skin

Question 8

Prognosis for vitiligo

Answer 8

Vitiligo is a chronic and persistent disorder characterized by periods of disease activity and inactivity
Spontaneous repigmentation may occur rarely
In up to 40% of cases there is recurrence of vitiligo despite treatment