Vitiligo
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Vitiligo
- 1. Block 4.1 (Medicine) by :Maryam AL-Qahtani
- 2. Objectives Discussion the case: History taking Differential diagnosis Physical examination Final diagnosis: Definition Etiology & Pathogenesis Classification Tests Prognosis and Treatment
- 3. Introduction 23 years old male, graduated from commerce college was anxious and worried regarding the white patches that affected his fingers and elbows.
- 5. Vitiligo : disorder in which white patches of skin appear on different parts of the body when the skin no longer forms melanin Chemically induced depigmentation : Working with chemicals such as phenols may cause depigmentation postinflammatory hypopigmentation : is a decrease in pigmentation rather than absence. is associated with a history of antecedent trauma or inflammation • Signs of inflammation
- 6. Pityriasis alba is a mild form of eczematous dermatitis that presents with hypopigmented macules and small patches on the face, and less frequently on the upper extremities. Fine scale may be visible. The disorder is most common in children with an atopic history. Idiopathic guttate hypomelanosis : characterized by multiple, small (<6 mm), well-defined, depigmented macules; lesions are most frequently found on the forearms and anterior lower legs • Usually related to sun exposure and start in leg Tinea versicolor : is a superficial fungal infection that can present as hypopigmented macules and patches with fine scale . The upper trunk and shoulders are most commonly involved, but other sites may be affected
- 7. History taking Personal data: Name Age Occupation Social status Education level. Main complaint
- 8. cont... History of skin lesions: When? ( + sudden or gradual ) Where? ( + other sites + other lesions + bilateral or unilateral ) associated symptoms : Is there Itching Redness (erythema) Pain What is the distribution of the lesion? How the lesion change ? (colour change , scale or bleeding ) Is there a correlation between the onset of skin lesions and any particular event or exposure?
- 9. cont... Past medical history : Chronic disease ? Operation? Illnesses ( hospitalization)? Skin disease ? Autoimmune disorders? Trauma ? Sun or Chemical exposure ? Family medical history of skin disease like vitiligo …… History of medication : When ? Dose ? such as prescription, over-the-counter, or herbal? Is it affective ?
- 10. cont... History of allergies Social history Sexual history Travel history
- 11. Case He had first seen a spot 2 years ago on elbows. It had gradually spread on both the fingers , knees, elbows, and thigh. No change in the lesion (no scale or bleeding ) No associated symptoms. No history of chronic disease , trauma or chemical exposure. Positive family history of vitiligo : grandfather. No history of medications.
- 13. DD Pityriasis alba Tinea versicolor Vitiligo
- 14. PE Identification of primary lesion (s) Site Size Shape Arrangement Number Surface Borders/edges Distribution Colour
- 15. Vitiligo
- 16. Definition Vitiligo is a condition of chronic skin disease in which a loss of cells that give color to the skin (melanocytes) results in smooth, white patches in the midst of normally pigmented skin. Can also affect the mucous membranes, hair and the eye.
- 17. Etiology & Pathogenesis The cause of vitiligo is unknown Genetic Immune Trigger factor
- 18. Pathogenesis
- 20. Classification Segmental vitiligo (SV)Non-segmental vitiligo (NSV)
- 21. Non-segmental vitiligo (NSV): Mostly generalized over a large area of the skin and bilateral . Symmetry in the location of the patches of depigmentation. New patches also appear over time and can be generalized over large portions of the body or localized to a particular area. Can come about at any age.
- 22. Classes of non-segmental vitiligo: Generalized Vitiligo Universal Vitiligo Focal Vitiligo Acrofacial Vitiligo Mucosal Vitiligo
- 23. Segmental vitiligo (SV) : less common usually develops in one unilateral region has an earlier age of onset than generalized vitiligo Mostly Focal with some macules. It spreads much more rapidly than NSV. it is much more stable/static in course its association with autoimmune diseases appears to be weaker than that of generalized vitiligo.
- 24. Tests Wood Lamp Examination Dermatopath ology (skin biopsy) Electron Microscopy Laboratory Studies
- 25. Prognosis and Treatment o Vitiligo is a chronic disease. The course is highly variable, but rapid onset followed by a period of stability or slow progression is most characteristic. o There is no cure for vitiligo. The aim of treatment: is to reduce the contrast in color between affected and unaffected skin.
- 26. cont... The approaches to the management of vitiligo are as follows: Sunscreens Cosmetic Coverup Repigmentation Depigmentation
- 27. cont... Repigmentation Localized Macules • Topical glucocorticoids • Topical calcineurin inhibitors: Tacrolimus and pimecrolimus. • Topical photochemotherapy [topical 8- methoxypsoralen (8-MOP) and UVA] • Excimer laser (308 nm) Best results in the face. Generalized Vitiligo • Systemic photochemotherapy: PUVA therapy(Psoralen+ UVA) • Narrow-band UVB, 311 nm.
- 28. cont... Depigmentation The objective of depigmentation is “one” skin color in patients with extensive vitiligo or in those who have failed or reject other treatments. Treatments: • Bleaching of normally pigmented skin with monobenzylether of hydroquinone 20% (MEH) cream is a permanent, irreversible process. • The success rate is >90%.
- 29. Michael Jackson
- 30. Vitiligo is a disease in which the pigment cells of the skin, melanocytes, are destroyed in certain areas. Vitiligo results in depigmented, or white, patches of skin in any location on the body. Vitiligo can be focal and localized to one area, or it may affect several different areas on the body. Vitiligo tends to run in families.
- 31. References Fitzpatricks Color Atlas and Synopsis of Clinical Dermatology , 7th Edition. Vitiligo- UpToDate. The Merck Manual.
- 32. THANK YOU
Editor's Notes
- major psychological problem for brown or black persons, resulting in severe difficulties in social adjustment.
- The differential diagnosis includes: ●Postinflammatory hypopigmentation – In this disorder, there is a decrease in pigmentation rather than absence, as in vitiligo. In addition, postinflammatory hypopigmentation is associated with a history of antecedent trauma or inflammation; one cause is liquid nitrogen therapy. ●Chemically induced depigmentation – Working with chemicals such as phenols may cause depigmentation (picture 6). ●Tinea versicolor – Tinea versicolor is a superficial fungal infection that can present as hypopigmented (not depigmented) macules and patches with fine scale (picture 7A-B). Lesions may also be hyperpigmented or salmon colored. The upper trunk and shoulders are most commonly involved, but other sites may be affected. (See "Tinea versicolor (Pityriasis versicolor)".) ●Pityriasis alba – Pityriasis alba is a mild form of eczematous dermatitis that presents with hypopigmented macules and small patches on the face, and less frequently on the upper extremities (picture 8A-B). Fine scale may be visible. The disorder is most common in children with an atopic history. (See "Approach to the patient with macular skin lesions", section on 'Pityriasis alba'.) ●Idiopathic guttate hypomelanosis – A common skin condition characterized by multiple, small (<6 mm), well-defined, depigmented macules; lesions are most frequently found on the forearms and anterior lower legs (picture 9A-B). ●Nevus depigmentosus (achromic nevus) – This is a solitary, stable, hypopigmented patch that is present at birth or appears in early infancy (picture 10). Occasionally, nevus depigmentosus may present in a segmental or linear pattern. ●Hypomelanosis of Ito – Hypomelanosis of Ito (aka incontinentia pigmenti achromians) typically presents at birth or in early infancy with hypopigmented patches in a whorled or linear pattern that follows the lines of Blaschko (picture 11). Lesions are usually found on the trunk or extremities. Associated neurologic, ocular, and/or skeletal abnormalities may be present. ●Piebaldism – The lesions in piebaldism, a genetically inherited absence of pigment, involve patches of depigmented skin with hyperpigmented borders occurring principally on the mid-forehead, neck, anterior trunk, and mid-extremities (picture 12A-B). Normal pigmentation occurs on the hands, feet, back, shoulders, and hips. (See "The genodermatoses", section on 'Piebaldism'.) ●Morphea – In morphea, the texture of the skin is firm secondary to sclerotic changes in the dermis (picture 13). ●Lichen sclerosus – The texture of the skin is thinned or inflamed (picture 14). There may be a follicular prominence, with complaints of burning, especially if the genitalia are involved. (See "Vulvar lichen sclerosus".) ●Leprosy – Areas of hypopigmentation will be anesthetic in leprosy. (See "Epidemiology, microbiology, clinical manifestations, and diagnosis of leprosy".) ●Rarely, hypopigmented patches resembling vitiligo may precede a diagnosis of cutaneous melanoma [40-43]. In patients with melanoma, vitiligo-like depigmentation is thought to be a marker of an immune response against melanoma cells and may be an indicator of favorable prognosis in advanced disease [44]. Tinea versicolor Tinea versicolor The first sign is usually small spots on the skin, which are generally lighter than the surrounding skin. Sometimes the spots are darker. The spots may be tan to pink, or very faint. The affected skin may be itchy and show spots which are scaly.. A fine scale is often present on affected skin, which becomes more apparent when the lesion is scraped for microscopy. Individual lesions are typically small, but frequently coalesce into larger patches Pityriasis alba central zone of bluish hyperpigmentation surrounded by a hypopigmented, slightly scaly halo of variable width. Patients display lesions primarily on the face. What is Pityriasis Alba? Pityriasis Alba is a common skin condition that generally affects children and young adults. It is characterized by the development of white patches of scaly rashes on the skin of the face which may also appear on the skin areas of the neck, arms and the upper chest. It is a self-limiting skin condition that usually resolves with ample application of skin moisturizer and creams. Pityriasis Alba is a common skin disease among children usually by the time they have reached school age and may also occur in young adults. The peak onset at age is usually from 12 years of age and below with occasional occurrence in young adults. It is not a seasonal skin condition while the dryness of the skin affected tends to worsen during the cold weather and air is relatively dry. The skin patches on the face become more apparent during the summer months and when the rashes are exposed to the sun. Pityriasis Alba is prevalent in children between the age of 6 to 16 years and who are living in countries or places with tropical climate. It occurs without racial predilection although the development is prevalent among light skinned individuals and is more common in males than in females. Pityriasis Alba is sometimes mistaken or confused with other skin condition such as tinea versicolor and vitiligo. Tinea versicolor can be ruled out with the comparison of skin flakes through identification of fungal elements which are not usually found in Pityriasis Alba. Vitiligo is differentiated from Pityriasis Alba through the borders of the rash presented. The rash in vitiligo is distinct from that of Pityriasis Alba where the border of the rash of vitiligo has sharp line while rash in Pityriasis Alba has fine edges between the normal skin and the light skin which makes it unnoticeable at times Symptoms Pityriasis Alba is marked by the onset of light colored patches on the surface of the skin particularly in the face and cheeks although it can also be noticed in the areas of the neck, arms and the upper chest. The skin patches have been made apparent during the winter months or cold season when the affected skin becomes dry due to the air condition inside the house. The skin patches become more apparent during the summer months when the patches are exposed to the sun and when the surrounding skin have darkened in color due to exposure under the sun. The lesions or the patches are usually oval-shaped with a size of approximately 0.5 to 2cm in diameter and may have a diameter of approximately 4cm when patches developed in the body. The lesions usually have a light pink or light red color during the initial onset and turns into white or light color as the condition progresses. Multiple lesions may occur on the face with a number ranging from 5 to 20 lesions or sometimes more. The development of the lesions usually takes 3 clinical stages and all stages are generally itchy for the affected individual. Papular erythematous lesion Papular erythematous lesion is the first stage that is often mild and characterized by redness which may go unnoticed by parents and significant others. Papular hypochromic lesion Papular hypochromic lesion is the second stage and is characterized raised lesions that have reddish discoloration. Itchiness is also present during this stage. Smooth hypochromic lesion Smooth hypochromic lesion is the third stage characterized by smooth and pale skin patches Idiopathic guttate hypomelanosis Usually related to sun exposure and start in leg
- The differential diagnosis includes: ●Postinflammatory hypopigmentation – In this disorder, there is a decrease in pigmentation rather than absence, as in vitiligo. In addition, postinflammatory hypopigmentation is associated with a history of antecedent trauma or inflammation; one cause is liquid nitrogen therapy. ●Chemically induced depigmentation – Working with chemicals such as phenols may cause depigmentation (picture 6). ●Tinea versicolor – Tinea versicolor is a superficial fungal infection that can present as hypopigmented (not depigmented) macules and patches with fine scale (picture 7A-B). Lesions may also be hyperpigmented or salmon colored. The upper trunk and shoulders are most commonly involved, but other sites may be affected. (See "Tinea versicolor (Pityriasis versicolor)".) ●Pityriasis alba – Pityriasis alba is a mild form of eczematous dermatitis that presents with hypopigmented macules and small patches on the face, and less frequently on the upper extremities (picture 8A-B). Fine scale may be visible. The disorder is most common in children with an atopic history. (See "Approach to the patient with macular skin lesions", section on 'Pityriasis alba'.) ●Idiopathic guttate hypomelanosis – A common skin condition characterized by multiple, small (<6 mm), well-defined, depigmented macules; lesions are most frequently found on the forearms and anterior lower legs (picture 9A-B). ●Nevus depigmentosus (achromic nevus) – This is a solitary, stable, hypopigmented patch that is present at birth or appears in early infancy (picture 10). Occasionally, nevus depigmentosus may present in a segmental or linear pattern. ●Hypomelanosis of Ito – Hypomelanosis of Ito (aka incontinentia pigmenti achromians) typically presents at birth or in early infancy with hypopigmented patches in a whorled or linear pattern that follows the lines of Blaschko (picture 11). Lesions are usually found on the trunk or extremities. Associated neurologic, ocular, and/or skeletal abnormalities may be present. ●Piebaldism – The lesions in piebaldism, a genetically inherited absence of pigment, involve patches of depigmented skin with hyperpigmented borders occurring principally on the mid-forehead, neck, anterior trunk, and mid-extremities (picture 12A-B). Normal pigmentation occurs on the hands, feet, back, shoulders, and hips. (See "The genodermatoses", section on 'Piebaldism'.) ●Morphea – In morphea, the texture of the skin is firm secondary to sclerotic changes in the dermis (picture 13). ●Lichen sclerosus – The texture of the skin is thinned or inflamed (picture 14). There may be a follicular prominence, with complaints of burning, especially if the genitalia are involved. (See "Vulvar lichen sclerosus".) ●Leprosy – Areas of hypopigmentation will be anesthetic in leprosy. (See "Epidemiology, microbiology, clinical manifestations, and diagnosis of leprosy".) ●Rarely, hypopigmented patches resembling vitiligo may precede a diagnosis of cutaneous melanoma [40-43]. In patients with melanoma, vitiligo-like depigmentation is thought to be a marker of an immune response against melanoma cells and may be an indicator of favorable prognosis in advanced disease [44]. Tinea versicolor Tinea versicolor The first sign is usually small spots on the skin, which are generally lighter than the surrounding skin. Sometimes the spots are darker. The spots may be tan to pink, or very faint. The affected skin may be itchy and show spots which are scaly.. A fine scale is often present on affected skin, which becomes more apparent when the lesion is scraped for microscopy. Individual lesions are typically small, but frequently coalesce into larger patches Pityriasis alba central zone of bluish hyperpigmentation surrounded by a hypopigmented, slightly scaly halo of variable width. Patients display lesions primarily on the face. What is Pityriasis Alba? Pityriasis Alba is a common skin condition that generally affects children and young adults. It is characterized by the development of white patches of scaly rashes on the skin of the face which may also appear on the skin areas of the neck, arms and the upper chest. It is a self-limiting skin condition that usually resolves with ample application of skin moisturizer and creams. Pityriasis Alba is a common skin disease among children usually by the time they have reached school age and may also occur in young adults. The peak onset at age is usually from 12 years of age and below with occasional occurrence in young adults. It is not a seasonal skin condition while the dryness of the skin affected tends to worsen during the cold weather and air is relatively dry. The skin patches on the face become more apparent during the summer months and when the rashes are exposed to the sun. Pityriasis Alba is prevalent in children between the age of 6 to 16 years and who are living in countries or places with tropical climate. It occurs without racial predilection although the development is prevalent among light skinned individuals and is more common in males than in females. Pityriasis Alba is sometimes mistaken or confused with other skin condition such as tinea versicolor and vitiligo. Tinea versicolor can be ruled out with the comparison of skin flakes through identification of fungal elements which are not usually found in Pityriasis Alba. Vitiligo is differentiated from Pityriasis Alba through the borders of the rash presented. The rash in vitiligo is distinct from that of Pityriasis Alba where the border of the rash of vitiligo has sharp line while rash in Pityriasis Alba has fine edges between the normal skin and the light skin which makes it unnoticeable at times Symptoms Pityriasis Alba is marked by the onset of light colored patches on the surface of the skin particularly in the face and cheeks although it can also be noticed in the areas of the neck, arms and the upper chest. The skin patches have been made apparent during the winter months or cold season when the affected skin becomes dry due to the air condition inside the house. The skin patches become more apparent during the summer months when the patches are exposed to the sun and when the surrounding skin have darkened in color due to exposure under the sun. The lesions or the patches are usually oval-shaped with a size of approximately 0.5 to 2cm in diameter and may have a diameter of approximately 4cm when patches developed in the body. The lesions usually have a light pink or light red color during the initial onset and turns into white or light color as the condition progresses. Multiple lesions may occur on the face with a number ranging from 5 to 20 lesions or sometimes more. The development of the lesions usually takes 3 clinical stages and all stages are generally itchy for the affected individual. Papular erythematous lesion Papular erythematous lesion is the first stage that is often mild and characterized by redness which may go unnoticed by parents and significant others. Papular hypochromic lesion Papular hypochromic lesion is the second stage and is characterized raised lesions that have reddish discoloration. Itchiness is also present during this stage. Smooth hypochromic lesion Smooth hypochromic lesion is the third stage characterized by smooth and pale skin patches Idiopathic guttate hypomelanosis Usually related to sun exposure and start in leg
- 1. The autoimmune theory holds that selected melanocytes are destroyed by certain lymphocytes that have somehow been activated. 2. The neurogenic hypothesis is based on an interaction of the melanocytes and nerve cells. 3. The self-destruct hypothesis suggests that melanocytes are destroyed by toxic substances formed as part of normal melanin biosynthesis.
- Generalized Vitiligo: the most common pattern, wide and randomly distributed areas of depigmentation. Universal Vitiligo: depigmentation encompasses most of the body. Focal Vitiligo: one or a few scattered macules in one area, most common in children. Acrofacial Vitiligo: fingers and periorificial areas. Mucosal Vitiligo: depigmentation of only the mucous membranes.
- Wood Lamp Examination. For identification of vitiligo macules in very light skin. Dermatopathology. In certain difficult cases, a skin biopsy may be required. Vitiligo macules show normal skin except for an absence of melanocytes. Electron Microscopy Absence of melanocytes and of melanosomes in keratinocytes. Laboratory Studies. Thyroxine (T4), thyroidstimulating hormone (radioimmunoassay), fasting blood glucose, complete blood count with indices (pernicious anemia), ACTH stimulation test for Addison disease, if suspected.
- The approaches to the management of vitiligo are as follows: Sunscreens The dual objectives of sunscreens are protection of involved skin from acute sunburn reaction and limitation of tanning of normally pigmented skin. Cosmetic Coverup The objective of coverup with dyes or makeup is to hide the white macules so that the vitiligo is not apparent. Repigmentation
- The approaches to the management of vitiligo are as follows: Sunscreens The dual objectives of sunscreens are protection of involved skin from acute sunburn reaction and limitation of tanning of normally pigmented skin. Cosmetic Coverup The objective of coverup with dyes or makeup is to hide the white macules so that the vitiligo is not apparent. Repigmentation Lesions located on the hands, feet, and joints are the most difficult to repigment. those on the face are easiest to return to the natural skin color.
- The approaches to the management of vitiligo are as follows: Sunscreens The dual objectives of sunscreens are protection of involved skin from acute sunburn reaction and limitation of tanning of normally pigmented skin. Cosmetic Coverup The objective of coverup with dyes or makeup is to hide the white macules so that the vitiligo is not apparent. Repigmentation