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Vitiligo

  • Author: Vlada Groysman, MD; Chief Editor: Dirk M Elston, MD  more...
 
Updated: Jun 19, 2015
 

Practice Essentials

Vitiligo is an acquired pigmentary disorder of the skin and mucous membranes that is characterized by circumscribed, depigmented macules and patches. The condition is frequently associated with disorders of autoimmune origin, with thyroid abnormalities being the most common. See the image below.

Trichrome vitiligo. Trichrome vitiligo.

Signs and symptoms

Vitiligo lesions are characterized as follows:

  • White or hypopigmented
  • Usually well demarcated
  • Round, oval, or linear in shape
  • Borders may be convex [1]
  • Range from millimeters to centimeters in size
  • Enlarge centrifugally over time at an unpredictable rate

Initial lesions occur most frequently on the hands, forearms, feet, and face, favoring a perioral and periocular distribution.

Clinical variants

  • Trichrome vitiligo: An intermediate zone of hypochromia is located between the achromic center and the peripheral unaffected skin; the natural evolution of the hypopigmented areas is progression to full depigmentation, resulting in 3 shades of color—brown, tan, and white—in the same patient
  • Marginal inflammatory vitiligo: Lesions have a red, raised border, which is present from the onset of vitiligo (in rare cases) or may appear several months or years after the initial onset; mild pruritus may be present
  • Quadrichrome vitiligo: Reflects the presence of a fourth color (ie, dark brown) at sites of perifollicular repigmentation [2]
  • Blue vitiligo: Results in blue coloration of vitiligo macules
  • Koebner phenomenon: Development of vitiligo in sites of specific trauma, such as a cut, burn, or abrasion

Clinical classifications

Vitiligo can be classified as follows:

  • Localized
  • Generalized
  • Universal

Localized vitiligo can exist in the following forms:

  • Focal: Characterized by 1 or more macules in 1 area, most commonly in the distribution of the trigeminal nerve
  • Segmental: Manifests as 1 or more macules in a dermatomal or quasidermatomal pattern; occurs most commonly in children; more than half the patients with segmental vitiligo have patches of white hair or poliosis
  • Mucosal: Mucous membranes alone are affected

Generalized vitiligo can manifest as the following:

  • Acrofacial: Depigmentation occurs on the distal fingers and periorificial areas
  • Vulgaris: Characterized by scattered patches that are widely distributed
  • Mixed: Acrofacial and vulgaris vitiligo occur in combination, or segmental and acrofacial vitiligo and/or vulgaris involvement are noted in combination

Universal vitiligo results in complete or nearly complete depigmentation. It is often associated with multiple endocrinopathy syndrome.

See Clinical Presentation for more detail.

Diagnosis

Although the diagnosis of vitiligo generally is made on the basis of clinical findings, biopsy is occasionally helpful for differentiating vitiligo from other hypopigmentary disorders.

Microscopic examination of involved skin shows a complete absence of melanocytes in association with a total loss of epidermal pigmentation. Superficial perivascular and perifollicular lymphocytic infiltrates may be observed at the margin of vitiliginous lesions, consistent with a cell-mediated process destroying melanocytes.

Other documented histologic findings include the following:

  • Degenerative changes in keratinocytes and melanocytes in the border lesions and adjacent skin
  • Increased numbers of Langerhans cells
  • Epidermal vacuolization
  • Thickening of the basement membrane

Loss of pigment and melanocytes in the epidermis is highlighted by Fontana-Masson staining and immunohistochemistry testing.[3, 4]

See Workup for more detail.

Management

Nonsurgical treatments

  • Systemic phototherapy: Induces cosmetically satisfactory repigmentation in up to 70% of patients with early or localized disease [5]
  • Laser therapy: Effective on limited, stable patches of vitiligo
  • Steroid therapy: Systemic steroids (prednisone) have been used, although prolonged use and their toxicity are undesirable [6]
  • Topical therapies
  • Depigmentation therapy: If vitiligo is widespread and attempts at repigmentation have not produced satisfactory results, depigmentation may be attempted in selected patients
  • Micropigmentation: Tattooing can be used to repigment depigmented skin in dark-skinned individuals

Surgery

The basic types of repigmentation surgery are as follow[7, 8] :

  • Noncultured epidermal suspensions
  • Thin dermoepidermal grafts
  • Suction epidermal grafting
  • Punch minigrafting
  • Cultured epidermis with melanocytes or cultured melanocyte suspensions

See Treatment and Medication for more detail.

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Background

Vitiligo is an acquired pigmentary disorder of the skin and mucous membranes, and it is characterized by circumscribed depigmented macules and patches. Vitiligo is a progressive disorder in which some or all of the melanocytes in the affected skin are selectively destroyed. Vitiligo affects 0.5-2% of the world population, and the average age of onset is 20 years.

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Pathophysiology

Vitiligo is a multifactorial polygenic disorder with a complex pathogenesis. It is related to both genetic and nongenetic factors. Although several theories have been proposed about the pathogenesis of vitiligo, the precise cause remains unknown. Generally agreed upon principles are an absence of functional melanocytes in vitiligo skin and a loss of histochemically recognized melanocytes, owing to their destruction. However, the destruction is most likely a slow process resulting in a progressive decrease of melanocytes. Theories regarding destruction of melanocytes include autoimmune mechanisms,[9] cytotoxic mechanisms, an intrinsic defect of melanocytes, oxidant-antioxidant mechanisms, and neural mechanisms.

Autoimmune destruction of melanocytes

The autoimmune theory proposes alteration in humoral and cellular immunity in the destruction of melanocytes of vitiligo. Thyroid disorders, particularly Hashimoto thyroiditis and Graves disease; other endocrinopathies, such as Addison disease and diabetes mellitus; and alopecia areata; pernicious anemia; inflammatory bowel disease; psoriasis; and autoimmune polyglandular syndrome are all associated with vitiligo.

The most convincing evidence of an autoimmune pathogenesis is the presence of circulating antibodies in patients with vitiligo.[10] The role of humoral immunity is further supported by the observation that melanocytes are destroyed in healthy skin engrafted onto nude mice injected with vitiligo patient sera.[11]

In addition to the involvement of humoral immune mechanisms in the pathogenesis of vitiligo, strong evidence indicates involvement of cellular immunity in vitiligo. Destruction of melanocytes may be directly mediated by autoreactive CD8+ T cells. Activated CD8+ T cells have been demonstrated in perilesional vitiligo skin. In addition, melanocyte-specific T cells have been detected in peripheral blood of patients with autoimmune vitiligo.[12, 13]

Intrinsic defect of melanocytes

Vitiligo melanocytes may have an intrinsic defect leading to melanocyte death. These melanocytes demonstrate various abnormalities, including abnormal, rough endoplasmic reticulum and incompetent synthesis and processing of melanocytes. In addition, homing-receptor dysregulation has also been detected. Early apoptosis of melanocytes has also been suggested as a cause of reduced melanocyte survival; however, subsequent investigation found that the relative apoptosis susceptibility of vitiligo melanocytes was comparable with that of normal control pigment cells.[14]

Disturbance in oxidant-antioxidant system in vitiligo

Oxidant stress may also play an essential role in the pathogenesis of vitiligo. Studies suggest that accumulation of free radicals toxic to melanocytes leads to their destruction. Because patients with vitiligo exhibit a characteristic yellow/green or bluish fluorescence in clinically affected skin, this led to the discovery that the fluorescence is due to accumulation of 2 different oxidized pteridines. The overproduction of pteridines led to the discovery of a metabolic defect in tetrahydrobiopterin homeostasis in patients with vitiligo, which results in the accumulation of melanocytotoxic hydrogen peroxide.[1]

Because oxidative stress has been suggested to be the initial pathogenic event in melanocyte degeneration, several studies have been conducted to evaluate this theory. Recent investigations set out to evaluate the role of oxidative stress by measuring levels of the antioxidant enzymes superoxide dismutase (SOD) and catalase (CAT) in lesional and normal skin of patients with vitiligo and in the skin of normal control subjects. They concluded oxidative stress is increased in vitiligo, as indicated by high levels of SOD and low levels of CAT in the skin of vitiligo patients.[15]

Neural theory

Case reports describe patients afflicted with a nerve injury who also have vitiligo have hypopigmentation or depigmentation in denervated areas. Additionally, segmental vitiligo frequently occurs in a dermatomal pattern, which suggests that certain chemical mediators are released from nerve endings that affect melanin production. Further, sweating and vasoconstriction are increased in depigmented patches of vitiligo, implying an increase in adrenergic activity. Finally, increased urinary excretion of homovanillic acid and vanilmandelic acid (neurometabolites) has been documented in patients with vitiligo. This may be a secondary or primary phenomenon.[2]

In summary, although the ultimate cause of vitiligo is not completely known, this condition does not reflect simple melanocyte loss, but possible immunologic alterations and other molecular defects leading to pigment cell destruction; however, melanocytes may be present in depigmented skin after years of onset and may still respond to medical therapy under appropriate stimulation.

Genetics of vitiligo

Vitiligo is characterized by incomplete penetrance, multiple susceptibility loci, and genetic heterogeneity.[16] The inheritance of vitiligo may involve genes associated with the biosynthesis of melanin, a response to oxidative stress, and regulation of autoimmunity.[17]

Human leukocyte antigens (HLAs) may be associated, but not in a consistent manner. For example, HLA-DR4 is increased in blacks, HLA-B13 is increased in Moroccan Jews, and HLA-B35 is increased in Yemenite Jews. An association with HLA-B13 is described in the presence of antithyroid antibodies.

A genome-wide association study of generalized vitiligo in an isolated European founder population identified that the group had significant association with single-nucleotide polymorphisms in a 30-kb LD block on band 6q27, in close vicinity to IDDM8, which is a linkage and an association signal for type I diabetes mellitus and rheumatoid arthritis. Only one gene, SMOC2, is in the region of association, within which SNP rs13208776 attained genome-wide significance for association with other autoimmune diseases and vitiligo.[18]

The age of onset has a genetic component; in another genomewide association study, a quantitative locus for age of onset was found in the major histocompatibility complex class II region near a region associated with generalized vitiligo susceptibility.[19]

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Epidemiology

United States

In the United States, the relative rate of vitiligo is 1%.

International

Vitiligo is relatively common, with a rate of 1-2%. Approximately 30% of vitiligo cases occur with a familial clustering of cases.

Sex

A female preponderance has been reported for vitiligo, but it is not statistically significant and the discrepancy has been attributed to an increase in reporting of cosmetic concerns by female patients.

Age

Vitiligo may appear at any time from birth to senescence, although the onset is most commonly observed in persons aged 10-30 years.

Vitiligo rarely is seen in infancy or old age. Nearly all cases of vitiligo are acquired relatively early in life.

The average age of onset for vitiligo is approximately 20 years. The age of onset is unlikely to vary between the sexes.

Heightened concern about the appearance of the skin may contribute to an early awareness of vitiligo among females.

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Contributor Information and Disclosures
Author

Vlada Groysman, MD Medical Director, Cahaba Dermatology and Skin Health Center; Clinical Assistant Professor of Dermatology, University of Alabama at Birmingham School of Medicine

Vlada Groysman, MD is a member of the following medical societies: American Academy of Dermatology, Women's Dermatologic Society, Medical Dermatology Society

Disclosure: Nothing to disclose.

Coauthor(s)

Naveed Sami, MD, FAAD Assistant Professor, Department of Dermatology, University of Alabama School of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

David F Butler, MD Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: American Medical Association, Alpha Omega Alpha, Association of Military Dermatologists, American Academy of Dermatology, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Phi Beta Kappa

Disclosure: Nothing to disclose.

Edward F Chan, MD Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania School of Medicine

Edward F Chan, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Mark G Lebwohl, MD Chairman, Department of Dermatology, Mount Sinai School of Medicine

Mark G Lebwohl, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Received none from Amgen for consultant & investigator; Received none from Novartis for consultant & investigator; Received none from Pfizer for consultant & investigator; Received none from Celgene Corporation for consultant & investigator; Received none from Clinuvel for consultant & investigator; Received none from Eli Lilly & Co. for consultant & investigator; Received none from Janssen Ortho Biotech for consultant & investigator; Received none from LEO Pharmaceuticals for consultant & inves.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Seung-Kyung Hann, MD, to the development and writing of this article.

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Trichrome vitiligo.
Marginal inflammatory vitiligo.
Segmental vitiligo.
Nonsegmental vitiligo.
 
 
 
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