vitiligo
VITILIGO
Vitiligo is an acquired, often familial, melanocytopenic disorder that produces focal depigmentation of the skin.
About half of the patients has onset of lesion before the age of 20.
It is a progressive disease wherein spontaneous repigmentation may occur within 6 months.
Precipitating factors include emotional stress, sunburn, chemical exposure, skin trauma, inflammation, irritation or rash that may precede the lesions by 2-3 months.
Lesions are white-colored macules or patches with well-defined borders and otherwise normal skin surface.

Classification

Nonsegmental (bilateral) vitiligo (NSV)

  • Also known as vitiligo vulgaris, generalized vitiligo
  • Chronic symmetrical depigmentation w/ an on-off cycle
  • Depigmentation starts then stops for some time, w/ progressive expansion of affected area
  • Usually starts on hands, feet or mouth

Segmental (unilateral) vitiligo

  • Asymmetrical depigmentation w/c usually begins in childhood
  • Remains stable after 1 yr of onset
  • Lesion follows a dermatomal pattern; may also have leaf-like or checkerboard pattern

Mixed vitiligo

  • NSV w/ segmental vitiligo

Unclassified vitiligo

  • Focal at onset, then progresses as multifocal w/ segmental & nonsegmental features
  • Serves as a diagnostic point until disease can be classified as NSV, segmental, or mixed

History

  • Onset of the lesion: 50% of patients first present before the age of 20
  • Course of the disease: Usually progressive
    • Spontaneous repigmentation may occur in 25-40% of patients w/in 6 mth
  • Precipitating factors: Eg emotional stress, sunburn, chemical exposure, skin trauma, inflammation, irritation or rash may precede lesions by 2-3 mth
  • Family history of vitiligo or premature graying of the hair
  • History of associated conditions (patient & patient’s family)
    • Eg thyroid disorders, alopecia areata, DM, pernicious anemia, collagen vascular diseases, Addison’s disease, melanoma, etc
  • History of ocular (eg loss of visual acuity, poor night vision, or photophobia) or auditory (eg deafness) disorders

Physical Examination

Morphology of the Lesions

  • Asymptomatic white colored macules or patches, w/ well-defined borders & otherwise normal skin surface
    • Occasionally, patients present w/ patches that have inflamed or hyperpigmented borders

Site of Distribution

  • Hypopigmented areas usually appear on exposed areas eg the dorsal surface of the hands & feet, the arms, face (lips & around mouth, nose & eyes), hyperpigmented areas (eg axilla, genital, around nipples), umbilicus, anus & at sites of trauma (Koebner’s phenomenon) & bony prominences (eg knee & elbow)

Other Important Physical Findings:

  • Depigmented hairs w/in vitiliginous areas & on the head (including eyelashes, beard, etc)
  • Changes in the choroid & retinal pigment epithelium
  • Uveitis

Screening

Scoring Systems

Vitiligo Area Scoring Index (VASI)

  • Quantifies total extent of depigmentation based on 5 sites: upper extremities, hands, trunk, lower extremities, feet
  • Uses a percentage scale to visually assess involvement & degree of skin pigmentation

Vitiligo European Task Force (VETF) System

  • Analyzes disease extent, stage, & disease progression
    • Extent - uses rule of nines
    • Stage - based on pigmentation of skin & hair
    • Stage Pigmentation
      0 normal (no depigmentation)
      1 incomplete depigmentation (includes spotty depigmentation, trichrome, light homogenous pigmentation)
      2 complete (hair whitening included <30%)
      3 complete w/ significant hair whitening (>30%)
    • Disease progression - assesses degree of spreading based on Wood’s lamp & electric light exams

Vitiligo Extent Tensity Index (VETI)

  • A recently formulated scoring system that produces a constant number based on the extent & severity of vitiligo
  • Uses the rule of nines; disease tensity is stages according to the affected area (head, upper extremities, trunk, lower extremities, genital area)
  • Further studies are needed to prove its potential in accurately diagnosing vitiligo

Diagnostic Examinations

Wood’s Lamp Examination

  • In patients w/ fair skin, it is used to detect vitiliginous lesions & in patients w/ darker skin, it is used to assess the degree of vitiligo lesions
  • May also be used to detect vitiligo lesions on the axillae, anus & genitalia which are often clinically inapparent

Other Exams

  • Additional laboratory exams may be needed for patients w/ history of autoimmune disorders
    • Anti-thyroid peroxidase, antithyroglobulin antibodies, thyroid function tests
  • Punch biopsy is suggested to differentiate vitiligo from other dermatoses
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