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Vitiligo
Definition
Vitiligo is a circumscribed, acquired, idiopathic,
progressive hypomelanosis of skin and hair which
is often fa...
Normal Skin Color
 Melanin
 Carotenoids
 Oxyhaemoglobin
 Reduced haemoglobin
Epidermal
Dermal
Normal Melanisation
Neuroectodermal Origin
Migrates to
Cutaneous
Epidermal
Appendageal
Mucous membrane
Follicular Non foll...
Normal Melanisation
Epidermal melanocyte
 Attached to basement membrane
 Rarely divide
 Require bFGF (Basic fibroblast ...
Hair melanocyte
Hair bulb
Hair follicle melanocyte
Mid-follicle + Upper follicle
• Dendritic
• Functional
• DOPA Negative
...
Normal Melanisation
Melanosome
 Membrane bound melanosome inside the
melanocyte
 Site of production and storage of melan...
Aetiopathogenesis
Vitiligo
Melanocytopenia
Pathogenesis
End organ disease Secondary to
• Auto antibodies
• Neural secretion
Aetiopathogenesis
 End organ disease
Apoptosis, Self destruction of melanocyte
Cause: ↑ amount, diffusion of intermediate...
Clinical features of Vitiligo
Macule of Vitiligo:
 Round, oval
Milky white
Scalloped margin
 Trichrome or quadrichrome
...
Clinical Classification
 Localized
◦ Focal
◦ Segmental
 Generalized
◦ Symmetrical
◦ Acromucosal
◦ Universalis
Cutaneous associations in Vitiligo
 Leucotrichia
 Premature gray hair
 Halo nevi
 Alopecia areata
Systemic associations in Vitiligo
 Thyroid disease
 Diabetes
 Addison's disease
 Pernicious anemia
 Multiple endocrin...
Differential diagnosis
 Piebaldism
 Pityriasis Alba
 Hansens disease
 Pityriasis Versicolor
 Morphoea
 Lichen Sclero...
Treatment guidelines
Vitiligo is a sign and the cause of melanocyte
destruction may not be the same in every case.
There i...
Aims of treatment
Repigmentation
 Prevention of further depigmentation
To increase melanin
Options:
 Increase number of melanocytes by promoting
migration from hair follicle.
 Activate dorman...
Medical Treatment
 Psoralen + UVA
 UVB – Narrowband
 Steroids
 Eau de Cologne
 Khellin + UVA
 L-phenylalanine + UVA
...
Treatment options for repigmentation
 Topical steroids - All types of vitiligo
 Topical PUVA - Focal / segmental
 Syste...
Prevention of further depigmentation
 Treatment of precipitating cause
 Steroid
◦ Topical (useful for repigmentation als...
PUVA (psoralen + UVA) therapy
 Drug + light
 Systemic/ Topical
Psoralen + UVA (320-400nm)
Trimethoxypsoralen, 8-methoxyp...
Cutaneous response after PUVA therapy
 Erythema
 Perifollicular pigmentation
 Inhibition of cell proliferation
 Rarely...
Treatment Protocol
TMP 0.6 mg/kg – 25 sittings
No change
TMP 0.9 mg/kg – 25 sittings
No change
8 MOP 0.3 mg/kg – 25 sittin...
PUVA Therapy
Follow up
Good response Development of
new patches
Total
pigmentation
Continue
maintenance
PUVA
Increase
dose...
PUVA Therapy: Side Effects
Acute
Erythema
Pruritus
Nausea
Headache
Koebner phenomenon
Chronic
Chronic actinic damage
Carci...
Topical steroids
 Isolated macules
 Hydrocortisone
 Mometasone
 Betamethasone
 Clobetasol
 Side effects
 Atrophy
 ...
Systemic steroids
 Low dose, long term
◦ Oral
◦ Injectable
 High dose pulse
 ACTH
Permanent depigmentation
 More than 50% area involvement
 Failure of treatment or does not wish to continue
treatment
 ...
Prognostic factors
 Acrofacial
 Patches on bony prominences
 Lesions on glans penis, palms, soles
 Patches with gray h...
Failure to respond to medical line of treatment
indicates melanocyte reservoir is no more
available in that area and it is...
Surgical treatment of vitiligo
 Tattooing
 Dermabrasion
 Exicision and closure
 Needling & spot peeling
 Punch grafti...
Thank you
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Vitiligo

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Vitiligo

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Vitiligo

  1. 1. Vitiligo
  2. 2. Definition Vitiligo is a circumscribed, acquired, idiopathic, progressive hypomelanosis of skin and hair which is often familial and is characterized microscopically by an absence of melanocytes. Leukoderma is the term applied only to depigmented patches of known causes eg: following burns, chemicals, inflammatory disorder.
  3. 3. Normal Skin Color  Melanin  Carotenoids  Oxyhaemoglobin  Reduced haemoglobin Epidermal Dermal
  4. 4. Normal Melanisation Neuroectodermal Origin Migrates to Cutaneous Epidermal Appendageal Mucous membrane Follicular Non follicular Extracutaneous Eye Brain Melanocyte
  5. 5. Normal Melanisation Epidermal melanocyte  Attached to basement membrane  Rarely divide  Require bFGF (Basic fibroblast growth factor) for growth and multiplication  Function - Endogenous sunscreen  Response to injury - Unpredictable
  6. 6. Hair melanocyte Hair bulb Hair follicle melanocyte Mid-follicle + Upper follicle • Dendritic • Functional • DOPA Negative • Amelanotic & Non dendritic • Active after trauma
  7. 7. Normal Melanisation Melanosome  Membrane bound melanosome inside the melanocyte  Site of production and storage of melanin  Membrane prevents diffusion of intermediate toxic products of melanin synthesis which are harmful to melanocyte
  8. 8. Aetiopathogenesis Vitiligo Melanocytopenia Pathogenesis End organ disease Secondary to • Auto antibodies • Neural secretion
  9. 9. Aetiopathogenesis  End organ disease Apoptosis, Self destruction of melanocyte Cause: ↑ amount, diffusion of intermediate products ↑ oxidative stress  Autoimmune Vitiligo antigen : Vit 40, Vit 75, Vit 90 Epidermal melanocytes express more vitiligo antigen than hair follicle melanocyte  Neural Nerve endings maybe secreting toxic substances which is detrimental to melanocyte
  10. 10. Clinical features of Vitiligo Macule of Vitiligo:  Round, oval Milky white Scalloped margin  Trichrome or quadrichrome  Confetti macules  Inflammatory border in some cases  Leucotrichia in some cases
  11. 11. Clinical Classification  Localized ◦ Focal ◦ Segmental  Generalized ◦ Symmetrical ◦ Acromucosal ◦ Universalis
  12. 12. Cutaneous associations in Vitiligo  Leucotrichia  Premature gray hair  Halo nevi  Alopecia areata
  13. 13. Systemic associations in Vitiligo  Thyroid disease  Diabetes  Addison's disease  Pernicious anemia  Multiple endocrinopathy syndrome
  14. 14. Differential diagnosis  Piebaldism  Pityriasis Alba  Hansens disease  Pityriasis Versicolor  Morphoea  Lichen Sclerosus et Atrophicus  Post inflammatory leucoderma
  15. 15. Treatment guidelines Vitiligo is a sign and the cause of melanocyte destruction may not be the same in every case. There is no uniform response to treatment.
  16. 16. Aims of treatment Repigmentation  Prevention of further depigmentation
  17. 17. To increase melanin Options:  Increase number of melanocytes by promoting migration from hair follicle.  Activate dormant melanocyte  Increase production of melanin from existing functional melanocyte
  18. 18. Medical Treatment  Psoralen + UVA  UVB – Narrowband  Steroids  Eau de Cologne  Khellin + UVA  L-phenylalanine + UVA  Topical Tacrolimus  Topical 5 Flurouracil  Topical Calcipotriol  Placental extract  Topical bFGF  Excimer laser
  19. 19. Treatment options for repigmentation  Topical steroids - All types of vitiligo  Topical PUVA - Focal / segmental  Systemic PUVA - Segmental / Generalized
  20. 20. Prevention of further depigmentation  Treatment of precipitating cause  Steroid ◦ Topical (useful for repigmentation also) ◦ Systemic Oral  Short course  Pulse Injectable  ACTH Triamcinolone
  21. 21. PUVA (psoralen + UVA) therapy  Drug + light  Systemic/ Topical Psoralen + UVA (320-400nm) Trimethoxypsoralen, 8-methoxypsoralen UVA chamber, PUVASOL Photometer to measure output Protective goggles
  22. 22. Cutaneous response after PUVA therapy  Erythema  Perifollicular pigmentation  Inhibition of cell proliferation  Rarely oedema and vesiculation
  23. 23. Treatment Protocol TMP 0.6 mg/kg – 25 sittings No change TMP 0.9 mg/kg – 25 sittings No change 8 MOP 0.3 mg/kg – 25 sittings No change 8 MOP 0.6 mg/kg – 25 sittings No change TMP + 8MOP – 25 sittings No response Unresponsive case
  24. 24. PUVA Therapy Follow up Good response Development of new patches Total pigmentation Continue maintenance PUVA Increase dose Stop PUVA
  25. 25. PUVA Therapy: Side Effects Acute Erythema Pruritus Nausea Headache Koebner phenomenon Chronic Chronic actinic damage Carcinoma - rare Immunosuppression Ophthalmic effect Premature cataract
  26. 26. Topical steroids  Isolated macules  Hydrocortisone  Mometasone  Betamethasone  Clobetasol  Side effects  Atrophy  Striae Children + Face Adults + Body
  27. 27. Systemic steroids  Low dose, long term ◦ Oral ◦ Injectable  High dose pulse  ACTH
  28. 28. Permanent depigmentation  More than 50% area involvement  Failure of treatment or does not wish to continue treatment  20% MBEH (monobenzyl ether of hydroquinone) – 4 to 12 months  Irreversible  Eyes, hair spared  Needs sunscreen afterwards  Side effect - contact dermatitis  Rarely accepted by Indian patients
  29. 29. Prognostic factors  Acrofacial  Patches on bony prominences  Lesions on glans penis, palms, soles  Patches with gray hair  Patches around nipple  Long standing cases  Extensive depigmentation Cases resistant to medical line of treatment
  30. 30. Failure to respond to medical line of treatment indicates melanocyte reservoir is no more available in that area and it is needed to repopulate that area with melanocytes which can be achieved by various surgical modalities
  31. 31. Surgical treatment of vitiligo  Tattooing  Dermabrasion  Exicision and closure  Needling & spot peeling  Punch grafting  Split thickness grafting  Suction blister grafting  Melanocyte grafting  Mesh grafting  Allograft
  32. 32. Thank you

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