Vitiligo

White spot disease

Acquired disease in which CD8+ T-lymphocytes attack melanocytes leading to depigmentation of the skin.

• Prevalence: approx. 1% (depending on source: 0.1%-4%)
  • Ethnic differences:
    • India: approx. 2-4%
    • Generally, patients with black skin colour are more often affected
• Peak age: 10-30 years, but any age is affected
  • 50% of cases before 20 yrs.
  • 25% of cases before the age of 10
• Women = men
• Familial clustering in 30-40%

• Generalised vitiligo (90%)
  • Acrofacial: face/ distal extremities
  • Vulgaris: irregular
• Localised vitiligo
  • 2% of cases
  • Focal: not located within a dermatome
  • Segmental: Arranged within a dermatome
  • Vitiligo of the mucosa: 0.5% of pat.
• Universal vitiligo
  • 8% of cases
  • > 80% of body surface area

As yet not explained in detail.

• Possible aetiologies:
  • Autoimmunological
  • Neural pathologies (segmentally arranged depigmentation)
  • Self-destruction hypothesis
    • During melanin synthesis, self-destruction of melanocytes occurs due to a lack of protective mechanisms.
  • Growth factor deficiency
    • Melanocytes are not destroyed according to this theory, but are not formed due to growth factor deficiency
  • Genetic factors
    • Susceptibility loci: AIS 1-3, NALP1

• Possible triggers:
  • Sunburn
  • Psychological stress
  • Thyreotoxicosis
  • Mechanical trauma
  • Birth

• Association with other conditions: 
  • Thyroid disorders
    • Hyper- and hypothyroidism
      • Morbus Graves
      • Hashimoto's thyroiditis
  • Endocrinopathies
    • Pernicious anaemia (1-8%)
    • Diabetes mellitus type I and II
    • Morbus Addison
  • Autoimmune diseases such as
    • Alopecia areata
    • Lupus erythematosus
    • Myasthenia gravis
    • Pemphigus vulgaris
    • Morbus Crohn's
    • Systemic scleroderma
    • Biliary cirrhosis
  • Neoplasia
    • Malignant melanoma, in the context of therapy with:
      • Interferon, interleukin or vaccine therapies
      • Immune checkpoint therapies e.g. ipilimumab

Sharply demarcated, often symmetrical, partly confluent, pigment-free, whitish macules. In some cases an erythematous border is visible (dermatitis circinata Miescher). Hair arising from follicles in the affected areas typically turn whitish (poliosis circumscripta).

• Clinic
  • Sufficient for diagnosis in most cases
  • Examination with the Wood light
• If necessary, biopsy
• Lab
  • BB, TSH, fT3, fT4, thyroid antibodies, APCA, ANAs, daily blood glucose profile
• In case of scaling
  • Tape strips / KOH preparation e.g. of pityriasis versicolor alba
• Ophthalmological consultation e.g. to seek asymptomatic uveitis or retinal pigmentary defect

Mostly on the face, hands, axillae / nipples / periumbilical or genitoanal region. First depigmentation is often seen periorally. Watch out for traces of tooth paste around the mouth in children - this imitates perioral vitiligo in the Wood light examination. Wiping with a wet tissue helps!

Decrease or absence of melanin and melanocytes (melanin and melan-A staining).

• Eye disorders (uveitis)
• Presbycusis

Frequent progression in relapses.

1. Fain PR et al. (2003) A genomewide screen for generalized vitiligo: confirmation of AIS1 on chromosome 1p31 and evidence for additional susceptibility loci. Am J Hum Genet 72: 1560-1564
2. Handa S et al. (2003) Epidemiology of childhood vitiligo: A study of 625 patients from North India. Pediatric Dermatol 20: 207-210
3. Scherschun L (2001) Narrow-band ultraviolet B is a useful and well-tolerated treatment for vitiligo. J Am Acad Dermatol 44: 999-1003
4. Taieb A et al. (2013) Vitiligo European Task Force (VETF); European Academy of Dermatology and Venereology (EADV); Union Européenne des Médecins Spécialistes (UEMS). Guidelines for the management of vitiligo: the European Dermatology Forum consensus. Br J Dermatol 168:5-19
5. Travis LB et al. (2003) Successful treatment of vitiligo with 0.1% tacrolimus ointment. Arch Dermatol 139: 571-574
6. Parsadet et al. (2003) Effectiveness of oral Gingko biloba in treating limites slowly spreading vitiligo. Clin Exp Dermatol 28: 285-287