Vitiligo is a disorder that appears as sharply demarcated, round or oval, completely white macules without scale. Menaloncytes (the cells that create melanin pigment) are depleted from the affected areas. Vitiligo typically starts as one or more small white spots that enlarge over time, possibly becoming confluent. The most commonly involved areas for vitiligo are the extensor surfaces (e.g. back of hands, elbows, knees) and periorificial areas (e.g. perioral, perirectal, perioccular). The cause of the disease is unknown.
With what can vitiligo be confused?
The absence of scale distinguishes vitiligo from pityriasis alba and tinea versicolor. Vitiligo may also be confused with postinflammatory hypopigmentation. Other depigmented lesions include nevus depigmentosus and nevus anemicus.
How is vitiligo diagnosed?
Vitiligo is usually diagnosed clinically; biopsy is usually not required. On Wood’s light examination, the lesions of vitiligo will appear “chalk white”; other less obviously affected areas may be revealed as well. The conditions is generally asymptomatic. Patients seek medical care for cosmetic concerns. It may be warranted to screen for thyroid disease, pernicious anemia and Addison’s disease, which are occasionally associated with vitiligo.
How is vitiligo treated?
The goal of therapy for vitiligo is to improve cosmetic appearance. Unfortunately, treatment for depigmentation is prolonged and in most cases not fully effective. Treatment with psoralen plus ultraviolet A (PUVA) is sometimes helpful, but numerous sessions are required. Narrowband UVB phototherapy may also be helpful, particularly in combination with calcipotriol cream. High potency steroids (e.g .clobetesol) can be helpful for limited disease. Calcineurin inhibitors (e.g. topical pimecrolimus and tacrolimus) have more recently been shown to be safe and effective; these agents are especially useful on the face where high potency topical steroids may cause skin atrophy. The 308 nm excimer laser has been reported to be effective as well. Operative treatment in the form of skin grafts and punch grafts are sometimes used. Cosmetic management with camouflage makeup (e.g. CoverMark, Dermablend) is useful either alone or as an adjunct to other treatments. Sunscreen over the depigmented area is important to prevent sunburn.
What is the prognosis for vitiligo?
Vitiligo is most often a chronic progressive disease. It may sometimes progress to complete body depigmentation. In some patients, repigmentation spontaneously occurs, but it is usually incomplete. Depigmentation of the retina occurs in up to 30% of patients. Uveitis occasionally occurs as well. Autoimmune thyroid disease, especially Graves disease and thyroiditis, are sometimes associated with vitiligo, as are pernicious anemia, Addison’s disease, and alopecia areata.
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