- Clinical science
Vitiligo is a common skin condition in which a patchy loss of epidermal melanocytes results in depigmentation. This loss is hypothesized to be a result of autoimmune destruction, oxidative stress, and/or intrinsic melanocyte defects in genetically predisposed individuals, and is commonly associated with other autoimmune diseases. The clinical course is highly variable, with unilateral or bilateral distribution of well demarcated, depigmented macules, which may progress during the course of disease. These lesions have a predilection for facial, acral, extensor, and sun-exposed areas of the body. Vitiligo is often a clinical diagnosis, but Wood's lamp examination, dermoscopy, and/or skin biopsy are useful in ambiguous cases. Limited disease may be controlled with topical corticosteroids or topical immunomodulators, while extensive or progressive disease may require systemic therapy, phototherapy, or surgery. Regardless of the treatment modality, patients continue to have episodes of skin depigmentation throughout their lives.
- Prevalence: 1–2% of the general population
- Peak incidence: 20–30 years; can occur in any age group
- Sex: ♂ = ♀
Epidemiological data refers to the US, unless otherwise specified.
- Vitiligo is characterized by an absence of melanocytes in the depigmented lesions.
- The etiology is unknown, but is thought to be multifactorial.
- May be triggered by stress or skin injury (e.g., sunburn)
According to location
Generalized (most common): widespread distribution of lesions, frequently with mucosal involvement
- Acrofacial: lesions mainly on the hands and face
- Vulgaris: patches that are widely distributed
- Mixed: combination of acrofacial and vulgaris, or segmental, acrofacial, or vulgaris
Localized: isolated area affected (e.g., dermatomal)
- Focal: one or more lesion in one area (commonly trigeminal nerve distribution)
- Segmental: unilateral, asymmetric lesions that follow dermatomal patterns
- Mucosal: Only the oral and genital mucosa are affected.
- Universal: Almost the entire body is affected.
- Hypochromic vitiligo/vitiligo minor: rare variant, with incompletely depigmented lesions; seen in patients with darker complexions
- Generalized (most common): widespread distribution of lesions, frequently with mucosal involvement
According to clinical course and prognosis
- Segmental: Early onset, rapidly spreading, depigmented lesions may remain unchanged for life.
- Nonsegmental : A family history and progression of disease is common.
- Well demarcated, depigmented (white) macules or patches , surrounded by normal skin
- Unilateral or bilateral distribution, with stable or slowly progressive lesions
- Commonly on the face (e.g., perioral and periocular regions), neck, scalp, acral surfaces (e.g., hands), extensor surfaces, or genitalia
- Leukotrichia: depigmented hair
- Coexisting autoimmune diseases (∼ 20% of patients)
- Depigmentation of the retina, without any effect on vision
- Usually a clinical diagnosis
- If diagnosis is uncertain:
- Serological markers of autoimmune disease (e.g., thyroid function tests and antithyroid antibodies) once vitiligo is confirmed
- Pityriasis alba: A common hypopigmented scaly patch seen in sun-exposed areas, esp. in children (resolves spontaneously or with topical steroids).
- macules on the trunk: a fungal infection characterized by scaly hypopigmented
- Idiopathic guttate hypomelanosis: multiple hypopigmented macules on the sun-exposed areas; common in elderly individuals
- Nevus depigmentosus: a well-defined area of depigmentation, present since birth/early childhood, which doesn't enlarge, and requires no treatment.
- Chemical leukoderma: loss of skin pigment due to contact with chemicals
The differential diagnoses listed here are not exhaustive.
- Sunscreen (to prevent burns)
- Concealing makeup for cosmetic reasons
- Limited disease
- Progressive or refractory disease