ACROFACIAL VITILIGO DR SASI ATTILI - Disclaimer- This PPT is loaded as student material "as is", from the VRF Vitiligo Master Class Barcelona November 2011; VRF does not endorse or otherwise approve it.

1. Sasi.K. Attili (UK), V R Attili (India)

2. - Disclaimer-
aterial "as is", from the VRF Vitiligo Master Class Barcelona November 2011; VRF does no

4. • Is mucosal vitiligo part of acrofacial?
• What about anogenital lesions?

5. 1. Acrofacial/ Lip-tip vitiligo
currently considered as a limited form of generalized
vitiligo (NSV) because of symmetrical acral
involvement with facial lesions.
2. Vitiligoid lichen sclerosus (VLS)

6. Lichen Sclerosus et Atrophicus, Hemorrhagic and Vitiligoid Type. Julio M.
Borda, Luis M. Mirande, and Jorge Abulafia. Abstracted by Orlando Canizares
for Arch Dermatol. 1961; 84: 698-706
Borda JM, Balas Re. Lichen sclerosus et atrophicus of a vitiligoid type (In
Spanish). Arch Argent Dermatol 1961; 11: 419–424.
Borda JM, Abulafia J, Jaimovich L. Syndrome of circumscribed
scleroatrophies. Dermatol Iber Lat Am 1968; 3: 179–202. (In English)
Attili VR, Attili SK: Lichenoid inflammation in vitiligo: A clinical and histopathologic
review of 210 cases. Int J Dermatol 47:663-669, 2008
Attili VR, Attili SK. Vitiligoid lichen sclerosus: a reappraisal. Indian J.Dermatol.
Venereol. Leprol. 2008; 74(2):118-21.
Attili VR, Attili SK. Lichen sclerosus of lips: a clinical and histopathologic study
of 27 cases. International journal of dermatology. 2010; 49(5):520-6.

7. 1. Acrofacial/ Lip-tip vitiligo
currently considered as a limited form of generalized
vitiligo (NSV) because of symmetrical acral
involvement with facial lesions.
2. Vitiligoid lichen sclerosus (VLS)
superficial variant of lichen sclerosus- presents
as asymptomatic vitiligoid depigmentation
involving acral, facial and genital areas
i.e clinical= vitiligo, histology= LS

8. Since VLS and acrofacial vitiligo look alike
and both involve the same areas, can they
both be differentiated?

9. Attili VR, Attili SK: Lichenoid inflammation in vitiligo: A clinical and histopathologic review of 210 cases. IJD 2008

11. • Aim: characterisation and differentiation of
acrofacial vitiligoid lesions
• History and a thorough clinical examination in all
patients
• A single biopsy was taken from patients with typical
macular lesions. Multiple biopsies were taken when
ever possible from patients with atypical lesions

12. • Acrofacial vitiligoid lesions were observed on
clinical examination in 54 patients.
• Genital depigmentation- associated in 26/54
patients.

13. Source & Number of LS* VLS** VL***
Biopsies reviewed
Acral (33/54) 7 8 (24%) 18
Facial (29/54) 2 17 (59%) 10
Genital (17/26) 2 13 (76%) 2
LS*- Both clinical and histological features of LS
VLS**- Clinical vitiligo with histological features of LS
VL***- No clinical or histological features of LS= vitiligo

14. Pattern Clinical LS Histological LS Potential missed diag.
Acral-Facial (28) 1(4%) 18/28 patients (64%) 10 / 28 (36%)
Acral-Facial-Genital (26) 10(38%) 23/26 patients (88%) 3 / 26 (12%)
6/26 patients (AFG) had biopsies from all three areas and 4 had LS in all the three
areas.
AF and AFG depigmentation therefore probably belong to the same spectrum with
AFG being the complete expression of the disease

21. • Racially restricted phenomenon?
• Casual clinical diagnosis of vitiligo. Biopsies are not
taken from atypical vitiligo lesions
Genital area is not routinely examined and patients
•
don’t complain re: genital lesions.
Most genital lesions in this series were discovered on
direct questioning and persuasive inspection

22. • Initial objective of differentiating AF vitiligo from
VLS was only successful to a limited extent
• Though individual lesions of vitiligo and VLS can
be differentiated in most cases by histo review
• a significant number of cases that do not fall into either
category
• Features of both vitiligo (symmetrical acral
depigmentation) and LS (clinical and histological features)
were observed concurrently in some patients.

23. 1. Lesions of vitiligo may have histologic changes
typical of LS (VLS)
2. Lesions typical of vitiligo both clinically and
histologically, are found in conjunction with LS

24. True association of vitiligo and LS?
• Association is not seen with the other clinical types of
vitiligo
• The clinical lesions are also atypical with punctate &
guttate depigmentation in acral distribution
Acrofacial vitiligoid lesions are early/ abortive
lesions of LS?
• Bilateral symmetry over hands and feet is not a known
feature of LS

25. • Further focused studies are needed to find out: If this is a
true association, superimposition of one over the other or a
distinct disease different from both vitiligo and LS.
• Mucosal, genital and acrofacial vitiligo are part of the same
spectrum
• Acrofacial vitiligo is probably distinct from Generalized
vitiligo with acral lesions
• shows punctate/ guttate lesions spreading in a centripetal
pattern, rarely affects the trunk and shows a high prevalence/
predisposition to LS
• ? Explains poor treatment response in acral lesions